Simulator system for medical procedure training

ABSTRACT

Implementations relate to medical simulations for medical procedure training. In some implementations, a system includes a simulation processing component including at least one processor and which generates a virtual environment using position signals that describe at least one of a position and a configuration of a physical surgical instrument relative to a physical surgical site. The simulation processing component updates the virtual environment according to changes in the position signals and according to control signals corresponding to inputs by a user of the system. The updating in cludes moving a virtual surgical instrument within the virtual environment, where an interaction of the virtual surgical instrument with a virtual surgical site is defined at least partly by a physical relationship between the physical surgical instrument and the physical surgical site. The simulation processing component outputs a representation of a simulation state signal indicative of a current state of the virtual environment.

BACKGROUND

Disclosed features concern medical training equipment and methods, andmore particularly medical training equipment and methods used fortraining in minimally invasive surgical procedures and techniques.

Medical procedures on patients can involve a variety of different tasksby one or more medical personnel. Some medical procedures areminimally-invasive surgical procedures performed using one or moredevices, including teleoperated medical devices. In some such systems, asurgeon operates controls via a console, which remotely and preciselycontrol surgical instruments that interact with the patient to performsurgery and other procedures. In some systems, various other componentsto the system can also be used to perform a procedure. For example, thesurgical instruments can be provided on a separate instrument device orcart that is positioned near or over a patient, and a video outputdevice and other equipment and devices can be provided on one or moreadditional units.

Systems have been developed to provide certain types of training in theuse of a teleoperated medical system. A simulator unit, for example, canbe coupled to a surgeon console instead of the actual other systemcomponents, to provide a surgeon with a simulation of performing theprocedure. With such a system, the surgeon can learn how simulatedinstruments respond to manipulation of the console controls.

However, surgeons and various other personnel may perform tasks on othercomponents of the teleoperated medical system during a medicalprocedure. For example, assistants may move and position teleoperatedarms and instruments of an instrument unit in the correct positions,which can have a significant effect on the procedure. It can bebeneficial for assistants to also be able to find needed informationquickly during a procedure.

In addition, it can be beneficial to quantify training and performanceof such tasks by surgeons and assistants, thereby enabling suchpersonnel to track progress and improve performance.

SUMMARY

Implementations of the present application relate to medical simulationsfor medical procedure training. In some example implementations, asystem includes a simulation processing component including at least oneprocessor and generating a virtual environment using position signalsthat describe at least one of a position and a configuration of aphysical surgical instrument relative to a physical surgical site. Thesimulation processing component updates the virtual environmentaccording to changes in the position signals and according to controlsignals corresponding to inputs by a user of the system. The updating ofthe virtual environment comprises moving a virtual surgical instrumentwithin the virtual environment, where an interaction of the virtualsurgical instrument with a virtual surgical site of the virtualenvironment is defined at least partly by a physical relationshipbetween the physical surgical instrument and the physical surgical site.The simulation processing component outputs a representation of asimulation state signal indicative of a current state of the virtualenvironment. Various implementations can include a dummy instrument,anatomical model, control console, display device, teleoperable medicaldevice, and/or other variations.

In some example implementations, a method includes coordinating asimulated medical procedure using a simulation processing component andreceiving position signals based on one or more positions of elements ofa teleoperable medical device moved by at least one trainee during thesimulated medical procedure. The elements are physically positionablerelative to a physical surgical site in order to perform the simulatedmedical procedure. Simulation state signals are determined based on theposition signals, where the simulation state signals are indicative of acurrent state of the simulated medical procedure including integrationof the position signals from the teleoperable medical device. Thesimulation state signals are sent to at least one output deviceoperative to output a representation of the simulation state signals.Various implementations of the method can include receiving the positionsignals in a simulated setup procedure for setup tasks performed by atrainee, and/or in a simulated surgical operation following thesimulated setup procedure, outputting real-time feedback information toat least one trainee performing the tasks, and other variations.

In some example implementations, a method includes receiving positionsignals indicating positions of one or more physical surgicalinstruments relative to a physical simulated surgical site in asimulated medical procedure. A virtual environment is updated based onthe position signals, where the virtual environment implements a virtualsurgical site corresponding to the physical surgical site. Controlsignals are received from a control console and indicate manipulation ofone or more input controls of the control console by a user. The methodupdates the virtual environment based on the control signals, includingmoving one or more virtual surgical instruments within the virtualenvironment. Interaction of the virtual instruments with the virtualsurgical site are based on the positions of the one or more physicalsurgical instruments relative to the physical surgical site. Simulationstate signals are output to at least one output device to cause outputof a representation of the simulation state signals, where thesimulation state signals are indicative of a current state of thevirtual environment. Various implementations of the method can includephysical surgical instruments being coupled to associated manipulatorarms of a teleoperated medical device, or physical surgical instrumentsbeing manually operated by one or more users relative to a physicalanatomical model, and other variations.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a diagrammatic illustration of an example simulation systemincluding a teleoperated medical system, according to someimplementations;

FIG. 2 is a block diagram illustrating an example of a simulationprocessing component and communication with other components of thesimulation system;

FIG. 3 is a flow diagram illustrating an example method for providing asimulated setup procedure according to one or more implementationsdescribed herein;

FIG. 4 is a flow diagram illustrating an example method for providing asimulated surgical operation according to one or more implementationsdescribed herein;

FIG. 5 is a diagrammatic illustration of aspects of an example systemwhich can be used for automated evaluation of simulated medicalprocedures;

FIGS. 6A and 6B are examples of training image screens which can bedisplayed on one or more display screens of a simulation system;

FIG. 7A shows one example simulation system including examples ofseveral components described herein;

FIG. 7B shows an example display screen provided on the surgeon consoleof FIG. 7A;

FIG. 8 is a perspective view of an example teleoperated medical deviceand anatomical model;

FIG. 9A shows another example simulation system including examples ofseveral components described herein;

FIG. 9B shows an example display screen provided on the surgeon consoleof FIG. 9A;

FIGS. 10A-10C illustrate examples related to tracking instruments withinan anatomical model;

FIGS. 11A and 11B are diagrammatic illustrations of one example of theuse of an anatomical model in simulated medical procedures that includethe use of both teleoperated and manual surgical instruments;

FIG. 12 is a flow diagram illustrating an example method for using ananatomical model with reference to FIGS. 11A-11B;

FIGS. 13A and 13B are diagrammatic illustrations of a second example ofthe use of an anatomical model in simulated medical procedures thatinclude the use of manual surgical instruments; and

FIG. 14 is a flow diagram that illustrates an example method for usingan anatomical model with reference to FIGS. 13A-13B.

DETAILED DESCRIPTION

The present application discloses features relating to simulatedsurgical procedures and training exercises. Various disclosedimplementations of simulation systems and methods provide and teachrealistic setup procedures for positioning, placement of simulationequipment for particular surgical procedures, as well as the realisticuse of such equipment for the actual surgical operation. Simulations caninvolve some or all of the components involved in every stage of actualmedical procedures and can involve any personnel in such procedures, toprovide highly realistic training. Various tasks performed during all ofthese simulated medical procedures can be recorded and evaluated, withappropriate feedback on performances provided, allowing a high degree ofanalysis in the details of the procedures and enabling trainees forevery function of a medical procedure to improve their skills moreefficiently. Various simulation features described herein can allowusers to learn and practice, and can allow quantification of userperformance and tracking of user progress.

Some implementations are described using a teleoperated medical systemsuch as a da Vinci® Surgical System (e.g., a Model IS3000, marketed asthe da Vinci® Si™ HD™ Surgical System), commercialized by IntuitiveSurgical, Inc. of Sunnyvale, Calif. Knowledgeable persons willunderstand, however, that features disclosed herein may be embodied andimplemented in various ways, including teleoperated and, if applicable,non-teleoperated (e.g., manual) embodiments and implementations.Implementations on da Vinci® Surgical Systems (e.g., the Model IS3000;the Model IS2000, commercialized as the da Vinci® S™ HD™ SurgicalSystem) are merely exemplary and are not to be considered as limitingthe scope of the inventive aspects disclosed herein.

Herein, a “setup procedure” or “surgical setup procedure” refers tosetup tasks that configure system components to perform one or morelater surgical operations. A “surgical operation” or “surgical siteprocedure” refers to the actual surgical operation including surgicaltasks at a surgical site. A “simulated medical procedure” or “simulatedsurgical procedure” can refer to the entire simulated procedureincluding setup procedure and surgical operation, or can include justsetup procedure or surgical operation. The term “teleoperated medicalsystem” refers to a system of one or more components used to performsurgical procedures using one or more master controller devices and oneor more slave teleoperated medical devices. A “teleoperated medicaldevice” can be a slave device controlled by a remote master device andcan include one or more elements, such as manipulator arms and/orsurgical instruments, that can be moved or manipulated in response tosignals provided by one or more of the master controller devices, suchas a control console or surgeon console operated by a user remotely fromthe teleoperated medical device. A “wet-lab” exercise refers to anyexercise on actual (real) tissue, such as tissue samples, a porcinemodel, or cadaver. A “dry-lab” exercise refers to an exercise usingnon-tissue models or objects, including “inanimate” exercises usingobjects such as foam (for suturing), rings on wires, etc.

FIG. 1 is a diagrammatic illustration of an example simulation system100 including a teleoperated medical system, according to someimplementations. Simulation system 100 can be used to simulate actualmedical procedures without using actual patients. Any simulated medicalprocedure or training activity that does not take place on an actualhuman patient can be performed using simulation system 100 or avariation thereof. For example, simulations of dry-lab training tasks(e.g., inanimate exercises) and/or wet-lab training tasks (e.g.,exercises on real tissue, porcine model, or cadaver) can be performed.

In the example shown, simulation system 100 can include a simulationprocessing component (or “processing component”) 102, a surgeon console104, a patient side cart 106, and a vision side cart 108. Othercomponents can additionally or alternatively be included in thesimulation system 100, as described in various implementations herein.

Simulation processing component 102 can coordinate, control, and/orimplement a simulation that involves the various other components of thesimulation system 100. The simulation simulates a medical procedureenvironment involving the system components as if an actual patient wereto be, or being, operated upon. In some implementations, the simulationprocessing component implements and controls the display of a virtualenvironment that includes a virtual surgical site depicting one or moreelements of an actual physical surgical site. Some implementations caninclude a physical surgical site that includes a physical model and/orobjects.

In some implementations, the processing component 102 can coordinatesimulation components of the simulation system and/or monitor and recordparameters obtained during simulated medical procedures.

The simulation is an interactive one that involves the simulationprocessing component 102 receiving a number of inputs from the othercomponents of the system based on user manipulation of those componentswithin the simulation. The simulation processing component also providesa number of outputs based on those inputs, where the outputs cancoordinate the components of the simulation system and provide output tousers of the system via any of different types of output devices(display screens, audio speakers, motors, etc.) provided on one or moreof the components of the system 100. For example, the simulationprocessing component can provide output to users via simulation statesignals provided to one or more output devices. The simulationprocessing component can also provide feedback information to users viasignals that it outputs.

The simulation state signals can be indicative of a current state of thesimulated medical procedure including integration of (e.g., influencefrom) inputs from one or more system components. The current “state” ofthe simulated medical procedure is the current point of progress orstatus in the performance of the medical procedure as influenced by theinputs of the components of the simulation system. For example, in someimplementations simulation state signals can indicate the currentpositions of physical teleoperated surgical instruments of ateleoperated medical device of patent side cart 106 with respect to aphysical surgical site, where these current instrument positionsindicate the current state of progress in positioning the surgicalinstruments relative to the site in the simulated medical procedure,e.g., in a setup procedure. For example, the simulation state signalscan also indicate events in the medical procedure, such as collisions ofany instruments with other instruments or surfaces, or mis-positioningof component elements. In some implementations, the current state of thesimulated medical procedure can include a current state of a virtualenvironment, such as a virtual surgical site, implemented by thesimulation processing component. For example, the simulation statesignals can include data that describes the virtual environmentincluding virtual representations and current positions of surgicalinstruments. Simulation state signals can indicate current positions ofvirtual surgical instruments in the virtual environment based on controlinput from a surgeon console 102, where the positions of the virtualsurgical instruments indicate the current state of a surgical task of asimulated medical procedure.

The output device(s) can output a representation of the simulation statesignals. The representation can be output using a variety of types ofoutput, such as graphical (e.g., fully virtual/synthetic images, fullycamera images, or combined camera/virtual images), tactile, haptic,aural, etc. For example, in a simulated setup procedure, the outputrepresentation can include graphical representations of physicalinstruments, displayed visual statuses, notifications, visual text andmarkers, audio cues and other output, haptic responses, and/or otheroutput. During a simulated surgical operation, the output representationcan include a displayed environment at the surgical site, such as avirtual environment or images of a physical site. In some examples, aninitial state of a virtual environment can be selected by the simulationprocessing component by providing various controlling output signals tothe other components, and users can experience current updates to thevirtual environment via the state simulation signals based on userinputs via components such as the surgeon console 104 and/or patientside cart 106. The output device(s) can also output representations ofsignals providing feedback information.

The simulation processing component 102 can be implemented using one ormore processors (e.g., microprocessors, integrated circuits, logic,and/or other processing circuitry), as well as memory, input/outputinterfaces, and other components, as described below. In someimplementations, simulation processing component 102 can be implementedas a particular external or standalone unit that is separate from theother components in the simulation system. In other implementations, theprocessing component 102 can be provided within or a part of one of theother components of the simulation system 100, and/or distributed withinmultiple other components of the system 100.

One or more master consoles 104, such as a surgeon console or controlconsole, can be included in system 100 to provide a user, such as asurgeon trainee, input controls by which surgical instruments can beteleoperated as well as various other controls. Surgeon console 104 canalso include output devices such as visual, audio, and/or haptic outputdevices. A user operates the controls to provide control input signalsto the simulation processing component. Control input signals can alsobe provided from a surgeon console 104 to one or more of the othercomponents of the simulation system, such as the patient side cart 106and/or vision side cart 108. For example, teleoperated slave instrumentarms of the patient side cart 106 can be controlled, e.g., each surgicalinstrument operated by one or more corresponding master controls of thesurgeon console. Some examples of such teleoperated medical devices andsurgical instruments are described below.

The surgeon console 104 communicates with the simulation processingcomponent 102 as indicated by connection 105. Connection 105 can be anytype of communication channel, such as one or more wires or cables,wireless connections, etc. The surgeon console 104 outputs signalsindicative of the manipulation of the controls of the console 104. Forexample, if a user moves levers, joysticks, or dials, selects particularbuttons or touchscreen, or selects other controls, corresponding signalsare provided to the simulation processing component 102. In someimplementations, these signals can be standard signals provided to theother components of a teleoperated medical system during an actualmedical procedure, such as patient side cart 106 and/or vision side cart108, where the simulation processing component 102 can process thesesame signals. In other implementations, simulation signals which arespecific to the simulation can be output by the surgeon console 104. Thesimulation processing component 102 can use the inputs to update avirtual environment of the simulation, for example.

In some implementations, the surgeon console 104 also can output signalsto one or more components of the simulation system 100, such as thepatient side cart 106 and/or the vision side cart 108. For example,signals received by the simulation processing component 100 can berelayed to these other components by the simulation processingcomponent. Alternatively, the surgeon console 104 can have separate,direct connections similar to connection 105 with one or more of theother components of the simulation system. The output signals can drivethe operation of these other components similarly to a teleoperatedmedical system that does not use a simulation processing component 102.

In addition, the surgeon console 104 receives signals on connection 105from the simulation processing component 102. These received signalsinclude signals that would normally be received by the surgeon console104 in an actual medical procedure, including simulation state signalsused to update visual, audio, and/or haptic output devices of thesurgeon console that provide a representation of the simulation statesignals via video, audio, and haptic output to its user. In someimplementations, these signals can be generated by the simulationprocessing component 102 to describe a current state of a simulated,virtual environment provided by the simulation processing component 102and displayed at the surgeon console. In some implementations, receivedsignals can include signals provided by one or more of the othercomponents of the simulation system, such as signals received at thesimulation processing component 102 from the patient side cart 106and/or the vision side cart 108 and then relayed to the surgeon console104 from the simulation processing component 102. In still otherimplementations, the simulation processing component 102 can receivesignals from one or more of the other components and can process orchange these signals based on the simulation run by the simulationprocessing component. The processed signals can then be sent to thesurgeon console 104 for its use. In some examples, the simulationprocessing component 102 can create augmented reality data that iscombined with or integrated into data received from the other componentsof the simulation system such as an image or video feed from anendoscope or other imaging device at the surgical site, and the combineddata can then be sent to the surgeon console 104 as simulation statesignals. In some implementations, the surgeon console 104 can haveadditional separate, direct connections similar to connection 105 withone or more of the other components of the simulation system to receivethe signals from those other components similarly to a teleoperatedmedical system that does not use a simulation processing component 102.

In some implementations, multiple master consoles 104 can be incommunication with the simulation processing component 102. For example,such multiple consoles can be each be operated by a dedicated usersimultaneously during a medical procedure, e.g., to have each usercontrol particular device instruments, to have one user assist the otherin surgical exercises, etc. Each such surgeon console 104 can sendsignals to the simulation processing component 102 and can receivesignals from the simulation processing component, e.g., describing avirtual environment. Some simulation implementations can allow a user ata console 104 to pass control of one or more surgical instruments(virtual and/or physical) or pass control of other components or inputsto a different user of a different console 104, e.g. by sending acommand to pass control via input controls of a console 104 or otherdevice (e.g., other control panel in system 100). In some cases, signalsappropriate to each surgeon console can be received at that console,e.g., outputting a different visual perspective on a simulated surgicalsite at each console 104 based on which instruments that the particularconsole controls. Some implementations can include features specific tosimulations having more than one console 104. For example, virtualpointers can be generated and displayed on display screens of theconsoles 104, where one operator at one console 104 (e.g. an expert) cancontrol the pointer and point to displayed objects as viewed by theother operator at the other console 104 (e.g., a new trainee).

One or more patient side carts 106 can be included in simulation system100 to provide realistic physical interactions of controlled devicesthat are made during an actual teleoperated medical procedure. Forexample, one or more users such as trainee assistants who operate thepatient side cart 106 can be trained during a simulated medicalprocedure using the actual patient-side devices used in teleoperatedmedical procedures. Some trainees (e.g., other, surgeon trainees) can betrained to operate the surgeon console 104 to control the patient sidecart 106, such as moving physical teleoperated arms or other elementsand/or other functions. Such features enable users to be realistically,accurately, and effectively trained during simulated medical procedures.

The patient side cart 106 can be a standalone device separate from theother components of the system 100. Cart 106 can include a variety ofdifferent mechanisms and devices to enable teleoperated medical surgeryon patients. In some examples, the cart 106 includes one or moremanipulable elements, such as multiple controlled manipulator arms 114that each can have one or more surgical instruments removably theattached thereto. Such arms and their surgical instruments can be drivenwithin particular ranges and modes of motion such as to allow a user ofthe surgeon console 104 to manipulate the instruments to perform asurgical medical operation on a patient. For example, actuators (e.g.,motors) in the arms and/or instruments of the cart 106 can be controlledby signals from the console 104 and can drive movement of theinstruments to perform surgical tasks.

In some implementations, additional patient side carts 106 can beincluded in simulations. Some patient side carts can includeteleoperated medical devices, while others can include other types ofdevices (other surgical instruments, video displays, operating roomtables, etc.). Still others can include both teleoperated medicaldevices and non-teleoperated devices.

A trainee user of the patient side cart 106 can perform a setupprocedure involving the cart 106 to permit a (e.g. simulated) surgicaloperation to take place. For example, this setup procedure can includetasks such as moving the cart to a proper position, and moving each arm114 to a proper position. In some implementations, the setup of thepatient side cart 106 can be with reference to a physical anatomicalmodel 120. For example, the anatomical model 120 can simulate a portionof a human patient or other subject, and can include various featuresallowing the surgical instruments of the patient side cart 106 to bepositioned properly. In some examples, to further set up the cart 106,the user places surgical instruments of the cart 106 within appropriateapertures of the anatomical model 120 (e.g., designated via portplacement), so that the instruments obtain access to a physical surgicalsite simulated within the interior of the model 120. Other setup tasksmay also be performed, such as installing the correct surgicalinstruments on the arms 114, selecting and operating particular controlsof the cart 106 to enable needed functions, adjusting the positing ofthe manipulator arms to achieve patient clearance or avoid collisions,etc.

The patient side cart 106 communicates with the simulation processingcomponent 102 as indicated by connection 107. Connection 107 can be anytype of communication channel, such as one or more wires or cables,wireless connections, etc. The patient side cart 106 can receive signalsfrom the simulation processing component 102 which control itsteleoperated functions, such as the movement of arms 114 and themanipulation of surgical instruments attached to the arms 114 and/orotherwise coupled to the cart 106. In addition, the patient side cart106 can receive other signals such as simulation state signals (e.g.,data) creating output from visual, audio, or other output devices on thecart 106 to the user of the cart. In some examples, signals received bythe patient side cart 106 can be generated by the simulation processingcomponent 102 based on an implemented virtual environment, and/or can beprovided by the surgeon console and passed through to the cart 106 bythe simulation processing component 102.

The patient side cart 106 also sends signals on connection 107 to thesimulation processing component 102. Such signals can include datadescribing the current states of the cart 106, including positions andorientations of the arms 114 and surgical instruments of the cart 106 asdetermined by sensors of the cart 106. For example, joint positionsensors, servo motor position encoders, fiber Bragg grating shapesensors, etc. can be used to determine kinematic information (positionand/or orientation) associated with the manipulator arms. The signalscan also include data describing a visual image of the physical surgicalsite as captured by an endoscope or other imaging instrument of thepatient side cart 106 and/or other images describing the surgical siteor simulated patient (e.g., rendered ultrasound images, patient vitalsigns, etc.). Other signals can also be sent, such as input datadescribing the cart user's actions or messages, audio data from amicrophone or generated by interactions of the cart's devices, and otherforms of data. Various other signals describing states can also be sent,such as the states of particular cart controls, functions, etc. In someimplementations, these signals can be standard signals provided to thesurgeon console 104 of a teleoperated medical system for an actualmedical procedure, where the simulation processing component 102 canprocess these same signals. In other implementations, simulation signalsspecific to a simulation can be output by the patient side cart 106. Thesimulation processing component 102 can use the signals to update thevirtual environment of the simulation, for example.

In some implementations, the patient side cart 106 can send its signalsto the simulation processing component 102, which generates appropriatesignals in response which are sent to the surgeon console. In some casesor implementations, the simulation processing component can relay one ormore of the signals from cart 106 directly to the surgeon console 104via connection 125. In still other implementations, the patient sidecart 106 can have additional direct connections to the surgeon console104, vision side cart 108, and/or other system components.

In some implementations, the anatomical model 120 can include its ownsensors and can provide signals to and/or receive signals from thesimulation processing component 102 on a connection similar toconnection 107. For example, a connection 121 can provide signalsbetween the anatomical model 120 and the simulation processing component102. Alternatively, the model 120 can connect to patient side cart 106which can relay signals between the model 120 and simulation processingcomponent 102. Such sensors on the model 120 can allow manual surgicalinstruments to be tracked by the simulation, as described in greaterdetail below.

Some implementations of system 100 can include other operating roomequipment (e.g., operating table supporting the model 120, assistivetables or carts for additional surgery or support functions, etc.) whichcan include connections and communication to the simulation processingcomponent 102 similarly to the anatomical model 120. For example, suchother equipment can be included in and its use evaluated for simulationtasks and procedures described herein.

One or more vision side carts 108 can be included in someimplementations of simulation system 100 to provide output informationto assistant users of the simulation system, and/or to hold equipmentsuch as vision and data processing hardware. The vision side cart 108can be a standalone device separate from the other components of thesystem 100. For example, in some teleoperated medical systems, a visionside cart 108 can be used by an assistant, such as the assistant thatsets up and operates the patient side cart 106. The vision side cart 108includes one or more visual output devices, such as display screens,which can output a variety of information useful to the medicalprocedure being performed. For example, the display screen can display aview of the surgical site as captured by an endoscopic camera providedon a surgical instrument of the patient side cart 106, which allows theassistant user to adjust the camera to positions needed for the surgicaloperation. The display screen can also display other output informationsuch as the states of one or more controls being activated by thesurgeon at the surgeon console, the states of other devices used in themedical procedure, etc.

The vision side cart 108 communicates with the simulation processingcomponent 102 as indicated by connection 109. Connection 109 can be anytype of communication channel, such as one or more wires or cables,wireless connections, etc. The vision side cart 108 can receive signalsfrom the simulation processing component 102 which control itsfunctions, such as simulation state signals causing display of a virtualenvironment simulating the surgical site or display of images capturedat the physical surgical site, display of status information related tovarious system components, and output of any other types of output(audio, haptic, etc.) via appropriate output devices of the cart 108. Inaddition, the vision side cart 108 can receive such signals provided bythe surgeon console 104 and relayed through to the cart 108 by thesimulation processing component 102.

The vision side cart 108 also sends signals on connection 109 to thesimulation processing component 102 and/or other components of thesystem 100. Such signals can include data describing the current statesof controls or other input devices on the vision side cart which wereactivated by a user. The signals can include data received by the visionside cart 108 from other components such as patient side cart 106 andrelayed by the cart 108 to the simulation processing component 102and/or surgeon console 104. In some implementations, signals output bycart 108 can be standard signals provided to the surgeon console 104 ofa teleoperated medical system, where the simulation processing component102 can process these same signals. In other implementations, specificsimulation signals can be output by the vision side cart 108. Thesimulation processing component 102 can use the signals to update thevirtual environment of the simulation, for example. In someimplementations, the vision side cart 108 can send its signals to thesimulation processing component 102, which generates appropriate signalsin response which are sent to the surgeon console 104 and/or to thepatient side cart 106. In some cases or implementations, the simulationprocessing component 102 can relay one or more of the signals from cart108 directly to other components, such as to the surgeon console 104 viaconnection 127. In still other implementations, the vision side cart 108can have additional direct connections to the surgeon console 104,patient side cart 106, and/or other components.

In some implementations, a variety of physical surgical instruments canbe used by the simulation system 100 to more fully simulate an actualmedical procedure. These surgical instruments can include complete,actual surgical instruments that are used in the actual medicalprocedure being simulated. For example, standard manual surgicalinstruments such as a cannula 130 and laparoscopic instrument 132 can beused, which can be instruments not requiring the teleoperated patientside cart 106. Furthermore, surgical instruments used with the patientside cart 106, such as surgical instrument 134 and sterile adapter/drapeinstrument 136 can be used, which are removably attached to teleoperatedmanipulator arms of the patient side cart 106.

Some implementations of simulation system 100 can also or alternativelyuse non-operational “fake” surgical instruments 138. These can beinstruments that are dummies used only for the simulation system and donot provide the full instrument functionality. For example, thenon-operational instruments 138 can include portions of instruments thatcan be attached to manipulator arms 114 like fully operationalinstruments, but need only be inserted in cannulas or apertures of theanatomical model 120. Thus a shaft and end effector can be removed froma dummy instrument, and/or dummy instruments can be hollow instrumentswith no mechanism, or other non-operational versions of instruments thatprovide a user the experience of setting up and using such instrumentsduring a simulated medical procedure.

FIG. 2 is a block diagram illustrating an example of a simulationprocessing component 102 and communication with other components of thesimulation system 100.

Simulation processing component 102 can include an input processingblock 202 which can perform various functions of the simulation. In someimplementations, the input processing block 202 can implement one ormore virtual environments for simulations provided by the simulationsystem. For example, the virtual environment can provide a twodimensional (2D) or three-dimensional (3D) environment that can simulatea physical surgical site or a portion thereof. In some examples, aportion of a human body can be simulated, including virtual models ofskin surfaces and internal organs or other body structures, as well asvirtual models of the surgical instruments and other objects used in anactual surgical operation. The virtual models can be changed and updatedby the simulation processing block 202 based on signals 210 provided bythe surgeon console 104 which indicate the manipulation of mastercontrols on the surgeon console which direct how the surgicalinstruments on the teleoperated arms of the patient side cart are to bemoved and manipulated. The signals 210 also can indicate other commands,such as entering particular usage modes, activating other surgicalfeatures (e.g., fluid spray, suction, etc.), or performing otherfunctions.

Furthermore, the input processing block 202 can receive signals 212 frompatient side cart 106. These signals can include the positions andorientations of the manipulator arms and surgical instruments of thepatient side cart, as well as statuses of various controls on the cart106 as described above. The input processing block 202 can also receivesignals 214 from the vision side cart 108, which can include statuses ofvarious controls on the cart 108, etc., as described above. The inputprocessing block 202 can also receive signals 215 from tracked devices218, which for example can include one or more sensors of the anatomicalmodel 120 that track manually operated surgical instruments. Othercomponents of the simulation system (not shown) can similarly providesignals to the input processing block 202, such as operating roomsensors that track component positions, etc.

The input processing block 202 can also receive signals 216 from asimulator user interface (UI) 220 in some implementations. The simulatorinterface 220 can present one or more options or selections to user(s)of the simulation system 100 to customize and/or select features of thesimulation of the medical procedure. The simulator interface 220 can bepresented on one or more of the components of the simulation system,such as surgical console 104, patient side cart 106, and/or vision sidecart 108. Alternatively, the simulator interface can be implemented onits own dedicated device, such as a computer system (desktop computer,laptop computer, server, portable device, etc.). For example, thesimulator interface 220 can display options to a user, such as a numberof different medical procedures to simulate, as well as various options,settings, and preferences for those medical procedures and for thecomponents used in the simulation system. These selections can beprovided in signals 216 to the input processing block 202. In someimplementations, a single interface 220 can present options forsimulated setup procedures as well as simulated surgical operations,thus allowing a unified interface to control simulated aspects of allstages of teleoperated medical procedures.

The simulation processing component 102 can also include an output block204. This block can provide signals to control or drive variouscomponents of the simulation system 100, as instructed by the simulationprocessing block 202. For example, some signals can be signals tocommand functions on a component, such as signals controlling actuatorson the patient side cart to move telemanipulator arms or to commandanother medical function (air suction, etc.). Some signals can besimulation state signals that cause an output to the user. For example,the output block 204 can send a signal 230 output to the surgeon console104 that provides video output on a display of the surgeon console, suchas data causing a display of a virtual surgical site and virtualsurgical instruments at the site that move in correspondence with auser's manipulation of the controls of the surgeon console 104.Similarly, the output block 204 can send signal 232 to patient side cart106, signal 234 to vision side cart, and signal 236 to simulatorinterface 220 to drive video displays on these components that arerelevant to their functions. For example, patient side cart 106 and/orvision side cart 108 can display a graphical virtual environment showingthe surgical site based on a position of one or more endoscopeinstruments or other imaging instruments. Other visual output can beprovided as well, such as status messages. In some implementations,output block 204 can send signals 235 to track devices to providestatuses, updates, etc. Other types of output can also be caused bysignals to components, such as audio and haptic output. Simulatorinterface 220 can display an interface that can update its visualappearance based on input received from a user as provided in signal236, such as a graphical user interface displaying graphical menu itemsand/or other selections and options, or other type of interface.

Simulation processing component 102 can also include memory 206 incommunication with the simulation processing block 202. Memory 206 canstore various data needed by the simulation processing block 202 andsimulation system 100. For example, program instructions forimplementing simulations and data describing one or more virtualenvironments, three-dimensional models, and various settings can bestored in memory 206. In addition, in some implementations, thesimulation processing component 102 can monitor parameters based onevents and actions occurring during simulated procedures, and can storesuch parameters in memory 206. For example, parameters such as timetaken to perform a task that the procedure, positions of componentsduring procedures, etc. can be stored, as described below.

FIG. 3 is a flow diagram illustrating an example method 300 forproviding a simulated medical procedure according to one or moreimplementations described herein. Method 300 can be controlled and/orcoordinated by the simulation processing component 102. In this example,a simulated setup procedure is described for configuring one or morecomponents of the simulation system before and in preparation for asimulated surgical operation that can be performed after the setupprocedure. This example assumes the use of a patient side cart 106having manipulator arms in the simulated setup procedure. Otherimplementations can include similar or equivalent setup components ortasks.

The simulated setup procedure of method 300 can be performed while oneor more user trainees are forming the setup tasks. For example, a singletrainee can be required to perform all the tasks to obtain comprehensivetraining. In other implementations, multiple trainees can besimultaneously or otherwise required to perform setup tasks for thesimulated procedure as in an actual surgical procedure. For example, onetrainee may be required to position components in operating room, anthertrainee place ports, and another trainee position manipulator arms fordocking. Advantages of the simulation system include the ability totrain multiple trainees on a single system and or at the same time.

In block 302, the simulation processing component receives simulationoption selections. These can be various selections to configure thesetup procedure, and can be input by a user from a displayed interface,such as a graphical user interface 220 displayed by a display device ofthe surgeon console 104 and/or of vision side cart 108, for example.Selections can include the type of surgical operation that is to be setup for simulation, such as procedures designed for general, urologic,gynecologic, transoral, cardiac, thoracic, and/or pediatric surgicaloperations. Selections can also include the particular system componentsto be used in the setup procedure, the experience level of the usertrainee(s) involved, a difficulty level of the simulation (novice,standard, expert, etc.), time parameters for the procedure, etc. In someimplementations, this interface can be the same interface used for thesimulated surgical operations performed after setup (e.g., as describedin FIG. 4 ).

In block 304, the simulation processing component receives and recordssignals indicating that the user is positioning one or more componentsof the simulation system. Such components may be required to bepositioned in particular locations in the simulation area, e.g.,absolute positions in the area or positions relative to each other. Forexample, the patient side cart 106 can be placed relative to anoperating table and/or anatomical model, and/or the vision side cart 108can be positioned relative to the patient side cart 106, surgeon console104, or other components. In some implementations, additional componentscan be positioned during setup simulation, such as the surgeon consoleand in any other components being used (anesthesia table, etc.). In someimplementations, the component positions can be tracked using sensors,such as sensors for cameras positioned over the physical simulationarea, sensors detecting the motion of the components, etc., and thesepositions can be sent to, monitored and recorded by the simulationprocessing component 102. A user can also indicate to the processingcomponent that he or she has completed placing the components of thesystem, e.g., by providing input via the vision side cart 108 or othercomponent. The simulation processing component 102 can record parameterssuch as the received signals and times taken to complete tasks, and canoutput signals causing feedback to be provided during this block. Forexample, feedback can include a visual and/or audio displaying ofinstructions as to placement, graphical spatial diagrams or maps ofactual and/or desired component placement, alerts when the user hasdeviated too much from appropriate placement, warnings when specificmeasures are not taken (e.g., moving the patient side cart withoutplacing the arms up), etc. Feedback can be displayed on one or more ofthe output devices of the system components, in some implementations.

In block 306, the method can receive signals indicating that the user ispositioning a model for the setup procedure. For example, in someimplementations static registration techniques can be used, where theuser can move manipulator arms and instruments of the patient side cart108 to touch the surface of the model at one or more known locations.Using the sensors tracking the position of the arms, the simulationprocessing component can determine the position and orientation of themodel in 3-D space relative to the elements of the patient side cart,such as manipulator arms and/or surgical instruments. For example, thisallows a virtual scene of the operating room and/or surgical site to berendered and also can allows the simulator system to provide directedfeedback, e.g., suggestions, evaluation and/or scoring, on which port(s)the user is currently using and how to move to the correct port, ifappropriate. Other methods can be used in other implementations, such asusing a laser alignment guide or docking an arm to a rigid fixture thatconstrains the position and orientation of the model. The user canindicate to the simulation processing component that he or she hascompleted positioning the model. In some implementations, the simulationprocessing component 102 can record parameters such as sensor signalsand times taken to complete tasks, and can provide feedback on userprogress of the tasks performed during this block, such as updatingvisual displays.

In other implementations, the positioning of the anatomical model can besensed at a later time in method 300 instead of at block 306. Forexample, the position and orientation of the model relative to theteleoperated medical device can be sensed after docking in block 310using sensors of the teleoperated arms, and/or using sensors of themodel.

In block 308, the simulation processing component receives and recordssignals indicating that the user is selecting or placing ports at aphysical surgical site for use in a surgical operation. For example, theports can be placed in an anatomical model positioned at and/orincluding the physical surgical site. The ports are apertures or otherlocations in the model through which surgical instruments will beinserted, and the ports have specific pattern or distance requirementsdepending on the target anatomy and surgical operation selected forsimulation. In some implementations, placing ports can include placingcannulas in selected apertures of the model (e.g., which can be detectedfrom sensors in the model in some implementations), such as cameracannulas and operating instrument cannulas so that the desired surgicalsite portions are in view of an endoscopic or other camera surgicalinstrument and are in operating range of operating instruments to beplaced in the cannulas. In some implementations, the system can detectthe placement of ports using sensors within the anatomical model, and/orusing sensors in the teleoperated arms after docking (described below).The user can indicate to the simulation processing component that he orshe has completed placing the ports. The simulation processing component102 can record parameters such as sensor signals and times taken tocomplete tasks, and can provide feedback on user progress or correctnessof the tasks performed during this block (such as the correctness ofposition of placed ports), including updating visual displays.

In block 310, the simulation processing component receives and recordssignals indicating that the user is positioning (“docking”) themanipulator arms and/or other elements of the patient side cart inappropriate positions and locations above or within selected ports ofthe model. For example, the user can position manipulator arms atparticular angles, distances from each other, etc., in view ofparameters such as mutual manipulator collision avoidance and requiredinstrument range of motion. The simulation processing component receivessignals from sensors in the arms of the patient side cart, whichindicate the positions and orientations of the manipulator arms. Variousimplementations allow the user to manually move the arms or otherelements by hand, and/or with remote control. The user can indicate tothe simulation processing component that he or she has completed thedocking. The simulation processing component 102 can record parameterssuch as sensor signals and times taken to complete tasks, and canprovide feedback on user progress or correctness of the tasks performedduring this block, such as updating visual displays.

In block 312, the simulation processing component receives and recordssignals indicating that a user is inserting the surgical instruments ofthe patient side cart in ports. The simulation processing componentreceives signals from sensors in the arms of the patient side cartand/or from sensors and surgical instruments which indicate thepositions of the surgical instruments relative to the arms and/orsurfaces of the model. Requirements can include particular distances oramounts of insertion, locking an instrument in place, etc. In someimplementations, sensors in the model can detect instruments withincannulas.

In some implementations, the surgical instruments are dummy instrumentsthat are not functional as surgical instruments. In addition, if manual(e.g., non-teleoperated) instruments are being used, sensors of themodel (and/or at other locations in the operating room) can trackpositions of such manual instruments. A user can indicate to the systemthat placement of the surgical instruments is complete. In someimplementations, the simulation processing component 102 can recordparameters such as sensor signals and times taken to complete tasksduring block 310. The processing component can also provide feedback inblock 312. This can include the simulation processing component 102outputting signals to cause a video display of various virtual images,progress indicators, suggestions, hints, warnings, etc. regardinginstrument insertion by one or more display screens of the simulationsystem.

In blocks 304-312, various types of video output can be provided. Forexample, an assistant user can view the display (e.g., at a vision sidecart 108) to assist in determining whether arms and/or surgicalinstruments are properly positioned during the setup procedure. Adisplay of the surgical site can include the current positions ofsurgical instruments and other objects at the surgical site. In someimplementations, the display shows captured images of the physicalsurgical site at the patient side cart and/or model, such as captured byan endoscope instrument or other imaging instrument of the patient sidecart (e.g. ultrasound sensors, patient vital sign sensors, etc.), modelcameras or sensors, and/or other visual sensors directed at the physicalsite. This setup can be used for training on inanimate/dry-lab models orlive tissue models, such as porcine or cadaveric training protocols.

In other implementations, the display shows a virtual environment andvirtual surgical site generated by the simulation processing componentand based on detected positions of surgical instruments and/or otherobjects at the physical surgical site. For example, the surgicalinstrument positions can be known from sensors in their manipulatorarms, and positions of other objects at the site can be known fromcaptured images sent by camera(s). The simulation processing componentgenerates the virtual environment based on these known images andpositions. The virtual surgical instruments and objects can be displayedto appear similar to their physical counterparts (if any), or can bedisplayed as virtual objects with different appearances in the virtualenvironment.

In some implementations, the virtual environment can include display ofrealistic surroundings such as would be seen in an actual medicalprocedure. For example, the background of the displayed surgical sitecan include body walls, blood vessels, or other realistic surroundings.In some implementations, the virtual environment can include accuraterepresentations of the physical objects at the site, while thebackground and surroundings of the site can be made to look realistic asan actual medical procedure (e.g., as shown in FIG. 8B).

In block 314, the simulation processing component can output feedbackinformation such as final parameters, metrics, score, and/or otherfeedback related to the setup procedure. In some implementations,feedback information may also or alternatively be displayed to thetrainee during the performance of or upon completion of one or moretasks or exercises (e.g., in blocks 304-312), so that the trainee canmonitor his or her progress or can compare his or her performanceagainst other persons from a novice to expert range.

For example, metrics can be determined from recorded parameters and caninclude the times expended by an assistant for various tasks during thesetup procedure, as well as a summary of the placement positions of thecomponents and instruments used in the setup. An evaluation and scorecan also be determined by the simulation processing component based onthe tasks completed by the user during the setup procedure, as describedin greater detail below. The simulation processing component can outputfeedback indicating the result of evaluation, such as how well thetrainee performed tasks, as well as hints or instructions for performingthe tasks better. Some or all of this information can be output on oneor more displays or other output devices of the simulation system.

In block 316, the method checks whether the setup is complete. Forexample, the simulation processing component 102 can evaluate theresulting positioning of the system components and determine whether thesystem components and surgical instruments are adequately placed toallow a surgical operation to continue. If any placements aresufficiently incorrect, or the user requests to repeat a stage, then inblock 318 the simulation processing component causes the user to repeatthe appropriate stages or blocks of the setup procedure.

If the setup is complete, then in block 320, the method can checkwhether a simulated surgical operation should be started on the samesimulation system used for the setup procedure. The surgical simulationmay have been indicated in the simulation selections of block 302, forexample. If a surgical operation simulation is to commence, the methodcontinues as described in FIG. 4 . Otherwise, the method ends, orvarious further actions may be taken to continue or repeat training,such as replacing a surgical task exercise at the physical surgical siteof the anatomical model with a different exercise.

FIG. 4 is a flow diagram illustrating an example method 400 forproviding a simulated surgical operation according to one or moreimplementations described herein. In this example, a simulated surgicaloperation is described for performing surgical tasks at a surgical site(virtual site and/or physical site). Method 400 can be controlled andcoordinated by the simulation processing component 102.

In some implementations, method 400 can be performed after the setupprocedure of FIG. 3 . Thus, such implementations can offer the abilityto use a simulation framework on a teleoperated medical system with aseparate surgeon console and patient-side cart to monitor and trackprogress and to display output and feedback, all under a single softwareand user interface (UI) framework. Method 400 is described assuming thesetup of the simulation system components has been completed asdescribed in FIG. 3 .

The simulated setup procedure of method 400 can be performed with one ormore user trainees performing the surgical tasks. For example, a singletrainee can be required to perform simulated surgical tasks using thesurgeon console. In other implementations, multiple trainees can besimultaneously or otherwise required to perform surgical tasks for thesimulated procedure as in an actual surgical procedure. For example, one(surgeon) trainee may be required to control instruments using thesurgeon console, while a different (assistant) trainee may be requiredto control an additional manual instrument at the surgical site, orperform some other assistant function (e.g., exchange instruments,adjust positions of arms on patient side cart, adjust brightness of theendoscope feed, adjust ports, pass sutures to a teleoperated instrumentusing a manual laparoscopic instrument, coordinate a uterine manipulatorto assist the console surgeon, etc.). Two (or more) surgeon trainees attwo (or more) surgeon consoles can divide control of tasks, exchangecontrol of instruments, and/or provide training to each other if, inother examples. Advantages of the simulation system include the abilityto train multiple trainees on a single system and or at the same time.

In block 402, the simulation processing component can receive optionsand selections for the simulation. Such selections can include the typeof surgical operation to be performed, particular stages or sub-stagesof the operation to be performed, the particular components and/orinstruments to be used, etc. For example, the same graphical interfaceused to provide selections to the setup procedure of FIG. 3 can be usedfor the surgical operation.

In block 404, the method checks whether the simulation is using only thesurgeon console, without other components such as a patient-side cartand vision side cart. For example, the user may have designated aconsole-only simulation in block 402. If only the surgeon console is tobe used, then in block 406, the simulation processing component 102outputs signals (such as simulation state signals) to display a virtualenvironment on the console display device. This virtual environment candepict the surgical site at which the user of the console will beoperating. For example, a 3-D virtual environment can be displayed,including virtual anatomical structures that appear similarly tocorresponding real anatomical structures. In addition, virtual surgicalinstruments controlled by the user of the console are also displayed inthe virtual environment. The particular virtual anatomical structuresand virtual surgical instruments displayed in the virtual environmentcan be based on the selections made in block 402, where the simulationprocessing component can determine the appropriate environment based onthe type of procedure selected and other selections made by the user.

In block 408, the simulation processing component provides other signalsto the console. The signals can include simulation state signals such asaudio data informing the user of any events or interactions occurring inthe virtual environment, haptic data for outputting haptic output at theconsole, and/or any other applicable data. In some implementations, theprovided signals can also include performance feedback information suchas metric, score, instructions, alerts, hints, or other information.

In block 410, the simulation processing component 102 receives signalsfrom the console. These signals can include directional or positioningsignals based on user manipulation of controls on the console, such ashand grips, buttons, foot pedals, and other controls. The simulationprocessing component can update the virtual environment based on thesignals received from the console, including moving virtual surgicalinstruments to correspond with the user input as if the user werecontrolling physical teleoperated surgical instruments. Simulationprocessing component 102 can also determine interactions of the virtualsurgical instruments with virtual anatomical structures, e.g., accordingto a physics model.

In block 411, the simulation processing component records parameterssuch as signals and events communicated during the simulation procedure.For example, such signals and events can be signals sent and received inblocks 406-410, alerts or other performance feedback provided in theseblocks, user input provided in these blocks, the times expended bytrainee(s) to complete surgical tasks, etc.

In block 412, the simulation processing component can check whether thesimulated surgical operation is complete. For example, the user canindicate that the simulation is over via input by console controls. Ifthe operation is not complete, the method returns to block 408 toreceive signals from the console and continue the simulation in thevirtual environment. If the operation is complete, the method continuesto block 438, described below.

If in block 404 the method finds that the simulated surgical operationis not only using a surgeon console, then the method continues to block416, in which the method checks whether the simulation will display avirtual environment. For example, a virtual environment can be displayedon a console display and other displays of the simulation system, suchas a display on the vision side cart, and can be a similar virtualenvironment as described above for block 406. If a virtual environmentis to be displayed, then in block 418 the simulation processingcomponent 102 outputs signals (such as simulation state signals) to oneor more components to display the virtual environment on displays. Themethod then proceeds to block 416, detailed below.

If in block 416 the method determines that a non-virtual environment isto be displayed, then images of a physical surgical site as captured bya camera are to be received and displayed. In block 420, the methodchecks if an augmented display is to be output. An augmented displayallows the display of computer-generated graphics over the imagescaptured by a camera. If not, the process continues to block 424. If anaugmented display is to be used, in block 422 the simulation processingcomponent processes visual overlay data to be overlaid on receivedimages. For example, such visual overlays can include text, graphics,and interface objects which provide feedback information such as alerts,instructions, etc. In some implementations, the visual overlays canprovide indicators to instruct where arms, surgical instruments, orother components of the system should be positioned.

In block 424, the simulation processing component 102 receives cameradata from one or more endoscopes and/or other imaging instruments (e.g.,ultrasound sensors, vital signs sensors, etc.) providing images of thephysical surgical site and/or simulated patient. For example, anendoscope can be one of the surgical instruments provided on an arm ofthe patient side cart. The simulation processing component 102 alsodetermines and outputs signals (such as simulation state signals) todisplay the images of the surgical site on display devices of thesystem, such as display screens at the surgeon console 104 and thevision side cart 108 (if being used). If no augmented images are beingused, the output signals include only the camera data. Otherwise, theaugmented visual overlay signals of block 422 are combined with thecamera images and the combined signals for output for display. Later inthe simulation, the signals are used to update the displays.

In block 426, the simulation processing component 102 provides any othersignals to the surgeon console and to other system components. Thesignals can include audio data for outputting audio at systemcomponents, haptic data for outputting haptic output at systemcomponents, etc. In some implementations these signals can includecontrol signals received from the surgeon console which the simulationprocessing component relays to the patient side cart and/or vision sidecart. Similarly, the signals can include position signals and/or controlsignals received from the patient side cart which the simulationprocessing component relays to the surgeon console and/or to the visionside cart. In some implementations, the provided signals can alsoinclude feedback information provided to system components, such asmetrics, scores, instructions, alerts, hints, or other information(and/or feedback information can be included in augmented visual data inblock 422).

In block 428, the simulation processing component 102 receives signalsfrom the surgeon console 104 and other system components, such as thepatient side cart 106 and the vision side cart 108 (if present). Forexample, control signals from the surgeon console can indicate themanipulations of controls on the console by the console user, such asmaster levers used to move and otherwise manipulate the arms andsurgical instruments of the patient side cart 106. Signals from thepatient side cart can include position signals from sensors inteleoperated arms and surgical instruments indicating the position andorientation of those arms and instruments. Signals from the vision sidecart can include control signals from controls on that cart operated byan assistant user. In some implementations where manual surgicalinstruments are being used with an anatomical model, the simulationprocessing component can receive signals from the model, which caninclude sensor signals indicating positions of manual surgicalinstruments inserted in or contacting the model.

In block 430, the simulation processing component records parameterssuch as signals and events communicated during the simulation procedure.For example, such signals and events can be signals sent and received inblocks 418-428, alerts or other performance feedback provided in theseblocks, user input provided in these blocks, the times expended bytrainee(s) to complete surgical tasks, etc.

The blocks 406-410 or blocks 416-428 can be implemented during aperformance of one or more surgical tasks and/or exercises of thesimulated surgical operation. For example, a user such as a traineesurgeon can perform a simulated exercise at a simulated surgical site byteleoperating the surgical instruments inserted through the cannulas inthe model, for by controlling virtual instruments. Such exercises caninclude suturing, manipulating objects, etc. at a virtual or physicalsurgical site, or one or more other simulated tasks. Assistant traineescan be performing patient-side tasks simultaneously or between tasks insome implementations.

In block 432, the simulation processing component checks whether anincorrect setup has been in place during the surgical operationsimulation. This can be the case when a setup procedure was simulatedbefore the surgical operation and included incorrect selection of modelports, positioning of system components (e.g., teleoperating arms,surgical instruments, or anatomical model), or included other incorrectsettings or selections. Such incorrect setup settings can have asignificant effect on a following surgical operation. For example,collisions may occur between arms or instruments, ranges of motion maybe blocked, limits of motion may be prematurely reached, etc. If thesimulated surgical operation was performed using this incorrect setup,then in block 434 the simulation processing component outputs feedbackto the one or more users of the simulation indicating the incorrectsetup and how and this incorrect setup has affected the surgicaloperation. For example, output feedback information can indicate that amis-positioned arm or surgical instrument caused surgical tasks to bemissed or performed poorly, unintended changes to be made to simulatedpatient tissue, etc. This feedback can also indicate the correct setupto allow the users to correct any errors. In some implementations, suchfeedback can be output at any point during the simulated surgicaloperation.

After block 434, or if the setup was correct, the method continues toblock 436, in which the method checks whether the simulated surgicaloperation is complete. For example, this can be indicated by one or moreusers providing input to the system to indicate the operation is over,or the simulation processing component can automatically determine thatthe operation is over based on evaluating component positions, theimages of the surgical site, etc. If the simulated operation is notcomplete, the method returns to block 416 to continue displaying thesurgical site environment and communicate signals between systemcomponents. If the simulated operation is complete, then the methodcontinues to block 438.

In block 438, the simulation processing component outputs feedbackinformation such as final parameters, metrics, score, and/or otherfeedback to the users of the simulation. In some implementations,feedback information may also be displayed to trainee(s) during theperformance of or upon completion of one or more exercises (e.g., inblocks 406-410 or 416-428), so that a trainee can monitor his or herprogress or can compare his or her performance against a database ofother persons from a novice to expert skill levels. Similarly asdescribed above for the setup procedure of FIG. 3 , metrics can bedetermined from parameters and can include the times taken by the usersfor various tasks during the surgical operation, a summary of theplacement positions of the components and instruments used in thesurgical operation, etc. An evaluation and/or score can also bedetermined by the simulation processing component based on the surgicaltasks completed by the user during the surgical operation, as describedbelow. The simulation processing component can output feedbackindicating the result of evaluation, such as how well the traineeperformed tasks, as well as hints or instructions for performing thetasks better. Some or all of this information can be output on one ormore displays and/or other output devices of the simulation system.

Evaluation and Guidance of Trainee Performance During Simulations

During the simulated setup procedures and surgical operations describedabove with respect to FIGS. 3 and 4 , various data and parametersassociated with the setup and surgical tasks can be monitored (measured)and recorded by the simulation processing component, such as thepositions and motions of components at different stages of the variousprocedures, the times to complete various tasks, and so on. The systemcan determine metrics and perform an automatic evaluation associatedwith one or more trainees' performances during the simulation based onrecorded parameters. The system can also provide real-time performancefeedback to trainees during the procedure and based on evaluations, inorder to provide guidance during the procedure and for later procedures.

In some implementations, an evaluation can include automaticallycomparing the parameters recorded during these procedures (and metricsdetermined therefrom) to stored reference parameters and metrics for thecorresponding tasks. The reference parameters can be correct or optimalparameters for these tasks or parameters previously-recorded duringprevious simulated medical procedures. Parameters associated withrelevant skills may be evaluated to measure trainee improvement or tocompare one trainee's performance parameters to corresponding parametersdemonstrated by other trainees (concurrent or historic) or by personsconsidered to have expert skill levels. Thus a trainee's skill level ina particular parameter may be evaluated relative to peers (e.g., todetermine the trainee's progress with reference to anticipatedimprovement) or relative to experts (e.g., to identify deviations from ahigh skill level). Both patient-side skills of FIGS. 3 and 4 (associatedwith actions physically near the patient's location, e.g., manipulatorarm position and orientation setup, cannula port placement, docking,assisting during surgical tasks, and the like) and surgeon-side skills(associated with performing surgical tasks in the surgical operation ofFIG. 4 , e.g., teleoperating or manually positioning an endoscopiccamera and moving tissue instruments at the surgical site) can beevaluated.

An evaluation component can measure parameters associated with the tasksperformed by a trainee, such as the overall completion time of alltasks, completion time of particular tasks, the position and orientationof manipulators or instruments, as well as other parameters of theactions taken by the trainee. In some cases, an evaluation can includedetermining one or more scores based on predetermined criteriaassociated with the parameters and the comparisons, where scores canindicate a performance level or skill of the trainee based on theperformance in associated tasks. For example, a score can be based onthe time needed to perform one or more tasks during the procedure and/orpositioning or movement of system components during the one or moretasks. A trainee skill level associated with a specified parameter canbe automatically scored by using kinematic and/or other sensorinformation obtained from a teleoperated medical system, such as fromsensors of manipulator arms and of surgical instruments.

For simulated setup procedures such as in FIG. 3 , an evaluation systemmay use sensor information to determine positions and orientations ofinstruments directed during an exercise. For example, the sensorinformation can include kinematic information from the manipulator armsobtained during the performance of blocks 304-310 (e.g., using remotecenter positions of the surgical instruments and setup joint values), aswell as sensor information from other sensors used in the procedure. Insome implementations, a kinematic setup template can be created thatdefines a specific effective or ideal manipulator position andorientation for a specific surgical task. Data associated with atrainee's surgical task exercise performance is compared against thetemplate to create a performance score. This comparison can be used todetermine if a trainee has properly selected ports for a specificsurgical task exercise, if manipulator arm setup joints and otherstructures are properly configured to place the associated manipulatorarms at a proper position and orientation, if cannula ports are properlypositioned and spaced to allow effective surgical site access withminimized manipulator collision avoidance, etc. The ideal templateinformation can be, for example, clustered or averaged positions,movements, and/or placements from prior performances of trainees and/orexperts, or known optimal positions for instruments, arm components,etc.

In another example, a task exercise time parameter may be measured bystarting a timer at the beginning of a cannula docking exercise andstopping the timer when the system senses that all manipulators havebeen properly docked to an associated cannula. As another example, atask exercise manipulator collision avoidance parameter may be measuredby comparing sensor information from each docked manipulator arm againsttemplate sensor information to determine how close a trainee has come toplacing the manipulators in prescribed ideal positions and orientationsor within prescribed position and orientation envelopes. Similarly,sensor information from the manipulator arms, in conjunction with knownphysical dimensions of an anatomical model 120 can be used to determineif a trainee has properly positioned the cannulas in a correct portplacement pattern in the model, or if the remote center of motion foreach cannula (the location on each cannula that stays stationary inspace as the manipulator arm moves) is correctly positioned so as tominimize tissue trauma at a patient's body wall.

Scores can be determined in a variety of ways. A trainee may be scored,for example, on how well port placement is selected for a selectedsurgical operation, or how long it takes to determine the correct portplacement. Or, a trainee may be scored on how the manipulator arms arecoupled to the placed cannulas (concerning, for example, manipulator armcollision avoidance) or how long it takes a trainee to couple themanipulator arms to cannulas placed in an anatomical model.

Metrics also may be sampled and/or determined to indicate a trainee'sperformance as he or she completes the exercise, and these intermediateevaluations may be plotted against a template to obtain a score. Forexample, historic data may indicate that specific acts should becompleted in a certain order in order to most effectively complete atask, sensor data may be used to show the actual order in which atrainee performed the acts, and differences between the recommendedversus actual order of acts completed is used to determine a trainee'sscore.

For surgical tasks performed during the surgical operation of FIG. 4 ,the system can similarly record and determine parameters such ascompletion time of one or more tasks of the exercise and arm positionsbased on kinematic data for computing metrics (e.g., movement volume,errors in the exercise, economy of motion of the instruments, etc.).Performance parameters can be measured at multiple times during theperformance of surgical tasks during exercises and metrics determinedfrom those parameters. In one example of a dry-lab exercise, a trainingexercise can require that the trainee pick up a ring with an operatinginstrument, move the ring along the pathway to a finish position(transferring the ring to another instrument controlled by a differenthand as needed) without dropping the ring, while moving the camera tokeep the ring and instrument tips in the center of view at all times,and while repositioning controllers to keep the trainee's hands incentral controlling positions. In another example of a suturingexercise, the trainee can be required to drive a needle in apredetermined pathway of suture holes in the component while keeping thesite in view of the camera, or suture an opening closed with spatialrequirements as to the locations of the sutures. Patient-side tasksduring a surgical operation (e.g., an assistant trainee guiding one ormore instruments at the surgical site, controlling accessory equipment,etc.) can have their performance similarly measured.

Scores and/or other results of the surgical operation evaluationindicate an estimated level or skill of the trainee for the evaluatedsurgical exercise. Some implementations can provide graphical feedback,e.g., indicating how close the operating instrument end effectors are toideal or correct positions for the surgical task, and/or ideal locationsfor sutures, cuts of tissue, etc. Some implementations can outputreal-time feedback during the task performance, such as indicators ofcorrect or incorrect sutures, instrument positions, hints to thetrainee, etc. Some real-time feedback can be instructional, indicatinghow instruments should be placed, moved, or positioned.

In some examples, parameters and/or scores can be determined a firsttime based on a particular user's or team's performance, and the sameparameters and/or scores can then be recorded at a second time duringthe performance of the same type of procedure. These parameters can thenbe compared to evaluate the same user's or team's performance forparticular procedure. In other examples, the parameters can be recordedfor different users or teams, and compared to evaluate and compare thedifferent users and teams.

Such scoring of a trainee based on simulation procedures allowsperformance and improvement of that trainee to be measured. In addition,a trainee can be scored in relation to other trainees or in relation tohistoric data in order to determine how well the trainee can perform therequired task and/or to evaluate the trainee's relative learning speedand effectiveness and/or determine the trainee's skill level. Also,aggregate historical scoring may reveal that trainees have difficultyperforming a certain task, and so training can be modified to improve atraining program for that task.

The methods of FIGS. 3 and 4 can also be used to measure and evaluateperformances of multiple trainees or teams at once and in various rolesduring a training exercise. For example, the simulation system canprovide training for teams of persons, such as one or more surgeons,assistants, nurses, etc. In some examples, one or more assistanttrainees can perform patient-side tasks for the methods of FIG. 3 and orFIG. 4 , and a surgeon trainee can perform surgical tasks in the methodof FIG. 4 while operating a console. Trainees other than the surgeon canuse an anatomical model to practice patient-side skills (e.g., portplacement, docking, system setup, camera and instrument insertion) sincethey will often perform these activities in the operating room. The teamcan also train their communication to perform and coordinate varioustasks such as exchange instruments, adjust ports, pass sutures using aconventional laparoscopic tool, coordinate a uterine manipulator toassist the console surgeon, etc.

In some implementations providing training for such teams of trainees,the evaluation and scoring methodology described above can be extendedto evaluate the performance of operating room teams in addition toindividual trainees. For example, various scores can be outputindicating the performance level or skill for coordinated team tasks.Such evaluation can be assisted by automated metrics to track progressand compare to historical data similarly as described above. Thesefeatures can help provide proficiency standards for teams to understandtheir efficiency and how they can improve.

Some examples of teleoperated medical procedure training, evaluation andscoring are described in co-pending U.S. patent application Ser. No.13/968,253, entitled, “Anatomical Model and Method for SurgicalTraining,” which is incorporated herein by reference in its entirety.

FIG. 5 is a diagrammatic illustration of aspects of an example system500 which can be used for automated evaluation of simulated medicalprocedures using simulation system 100. As shown in FIG. 5 , a medicaldevice 502 is used, which in this example can include an input devicesuch as a surgeon console 104, and/or a teleoperated medical device suchas patient side cart 106, or other system that is capable of providingdata concerning the position and/or orientation of one or more medicalInstruments. The medical device 502 provides parameter information 504to be stored in a memory 506 that is included in an evaluation system508. For example, evaluation system 508 can be implemented in thesimulation processing component 102 and memory 506 can be implemented inmemory 206, for example.

Parameter information 504 can include performance parameters for atrainee's performance and/or related data, such as kinematic informationor other sensor information as described above. Information 504 may beprovided, for example, via an application program interface (API)interface in the simulation system. Parameter information 504 can beprovided from a patient-side cart 106, and/or from other components ofthe system, such as information describing position and/or orientationof controls for a operator (such as a surgeon or trainee) on a surgeonconsole 104, vision side cart 108, etc.

In some implementations, anatomical model information 510 (e.g.,physical dimensions, locations of possible cannula ports, location ofsurgical manipulators or instruments, etc.) associated with ananatomical model 120 is also input to the memory 506. Ttemplateinformation 512 can also be input into memory 506, indicating baseline,desired, and/or correct parameters and data for comparison to traineeperformance parameters. Other parameter information can also be storedin memory 506, such as event data, e.g., recorded times related totrainee tasks and task completions, etc., and which can be collectedand/or determined by other components of system 100 or 500 such asprocessor 514, sensors of the system, etc. Thus, memory 506 can be oneor more physical memory locations that can store information thatevaluation system 508 uses to carry out an evaluation of a trainee'sperformance. Such an evaluation is executed by processor 514, which canbe one or more information processing devices (e.g., microprocessor(s)or other processing circuitry) that can be used to carry out theevaluation.

The evaluation results, such as one or more scores, guidance feedback,and/or other information, can be output via an output device 516, suchas a visible display on a display screen or other display device, aphysical printout from a printer, or other output. The individualexercise results may be added to historic data 520 (e.g., depending onan input at operator selection input 518), which in turn may be used tomodify template information 512. In some embodiments, an operator inputdevice 518 enables a training system operator to input variousselections related to training exercises, such as identifying aparticular surgical exercise task to be carried out, and/or identifyinga particular anatomical model that is being used. The evaluation systemcan automatically select the appropriate information (e.g., propertemplate information 512) to use to carry out the evaluation.

Embodiments of a evaluation system 508 may be embedded in teleoperatedmedical systems (e.g., with outputs displayed via the system's displays)or may be implemented, for example, on a separate small computer system,such as a laptop computer or other electronic device. Such evaluationsystems may also be networked to a central database to facilitate datacollection from a number of medical devices and from a population ofmedical personnel (e.g., surgeons) and to facilitate data and/or scoringcomparison within the trainee or surgeon population.

In addition to use for surgical system training, various featuresdisclosed herein may be used for tasks based on using manual surgicalinstruments in the simulated medical procedures. Scoring aspects fortraining can be adapted for training in such manual tasks, such asability to reach locations at the surgical site, instrumentinterference, camera position, surgeon comfort, etc. Automated scoringaspects can be based on sensing a position of one or more components,such as cannulas, surgical instruments, etc. by various sensors in ananatomical model and/or in other locations as described above.

Various implementations can provide results of evaluations and/orguidance feedback to trainees' during and after the simulatedprocedures, indicating differences to ideal or desired positions, times,metrics and/or scores, trainee level and/or skill, and suggestionsand/or instructions for the correct or desired results. For example,graphical diagrams can be displayed on a display device indicating howclose the manipulator arms are positioned to ideal or correct positionsfor the surgical task. Furthermore, some implementations can outputreal-time feedback during the performance of tasks, such as indicatorsof correct or incorrect placements and positions of surgicalinstruments, hints to the trainee, graphical indications of correctpositioning and orientation and the acceptable range of motions andplacements for particular instruments, etc. Some real-time feedback canbe instructional, indicating where and when in the procedure thatinstruments should be placed or positioned. The system can providetutorials to persons, demonstrating how to select ports in a model,position components, and dock manipulator arms.

FIGS. 6A and 6B are examples of training image screens 600 which can bedisplayed on one or more display screens of a simulation system asdescribed above. For example, the images on screen 600 can be displayedto assist and guide the user in placing the manipulator arms of thepatient side cart during a setup procedure.

In FIG. 6A, display screen 600 shows an image 602 of an exampleimplementation of a patient side cart, e.g., similar to a patient sidecart 706 of FIG. 7A below. The image 602 includes images of threemanipulator arms 604. In some implementations, during a setup simulationprocedure, a user physically moves the physical arms corresponding tothe arm images 604, where this motion is sensed by the simulationprocessing component (or other processing component) via arm sensors,and processing component causes the arm images 604 displayed on screen600 to move in correspondence with the physical arms.

Indications can also be displayed to indicate the status of the armsrelative to desired positions in a particular stage or block of a setupprocedure. For example, the image 602 can indicate that the position ofone or more of the arms of the physical side cart is currently incorrector suboptimal. In one example, display screen 600 can display anenclosed line or border 606 around an area of the image 602 that isincorrect in position. In this example, the left manipulator arm 604 isshown to be incorrect in an area of its joints which are circled by theline 606. The line 606 thus directs the viewer's attention to theincorrectly positioned area. In some implementations, a more preciseindication such as a highlight 608 of a particular joint canspecifically point out the incorrect positioning. For example, thehighlight 608 can be of a particular color, pattern, or otherdistinguishing mark. A legend 610 can indicate that particular problemthat indicated by highlight 608, which in this case is that the leftmanipulator arm (Patient Side Manipulator, PSM) 604 is not facingforward enough, e.g., toward an anatomical model. Additionalexplanations of the incorrect positioning can be displayed in someimplementations, if desired by the user.

FIG. 6B shows another example of display screen 600, in which adifferent portion of the physical patient side cart is incorrectlypositioned as indicated in the displayed image 602 of the patient sidecart. A line 616 indicates an area of the image 602 having inaccuratepositioning, which in this example is an endoscopic center arm (ECM),i.e., the center arm 604 of the patient side cart. A highlight 618indicates the particular joint of the arm 604 which should be corrected.For example, legend 610 informs the viewer that highlight 618 indicatesthat the center endoscopic manipulator 604 is not positioned in a “sweetspot” which allows the instrument of that harm to provide accurate oroptimal views when inserted in a patient or model for the currentlyselected surgical operation. Other types of lines, borders, and/orindicators can be displayed in other implementations, including visual,audio, haptic, or other forms.

Virtual reality or other generated images such as those of screen 600,and/or augmented reality (AR) ghost images overlaid on camera images,can be displayed on system display devices to indicate or highlightsystem areas of concern or interest to users. For example, manipulatorarm setup joints can have incorrect positions highlighted, as describedabove. In addition, reachability limits of manipulator arms and/orinstruments can be displayed. Furthermore, spatial areas where internalor external collisions between arms and/or instruments can behighlighted as zones for the user to be aware of.

In some implementations, feedback information such as suggestions can bedisplayed on screen 600. For example, text suggestions can indicate anestimated amount of movement which would cause a highlighted arm to themood into a correct position. Graphical suggestions can display correctpositions (e.g., in a different color or other format) on the samedisplay 600 relative to the current, incorrect positions. Broader hintscan also be provided to allow the user to exercise judgment or makedecisions. Such suggestions can guide the user in a training exercise tolearn the correct way to perform tasks.

A variety of other types of feedback information can also be displayedon one or more display screens during setup procedures and surgicaloperations to provide guidance on system setup and accurate positioningof the manipulator arms, as well as guidance on surgical tasks. Forexample, text information messages such as instructions and alerts canbe displayed to inform users of correct or incorrect actions orpositioning during procedures. Some feedback can be provided in otherforms, such as audio output or haptic output (e.g., on motor-controlledmanipulator arms and/or surgical instruments).

The simulation system can thus provide guidance and feedback to traineesfor system setup and skills during procedures such as dry-lab or wet-labpatient-side training scenarios. This can also reduce the burden ontraining assistants to constantly catch mistakes during simulationprocedures, especially when training multiple trainees simultaneously.The system can also provide guidance and feedback during surgicaloperations and tasks, e.g., to assistant users operating the patientside cart (and other components) and/or manual instruments at ananatomical model, as well as the surgeon trainee operating the surgeonconsole.

Example Implementations

Many different variations of simulated surgical procedures can beimplemented based on the simulation system 100 and methods describedherein. Some example simulation configurations are described below.

The simulation can include a setup procedure using the patient side cart106, vision side cart 108, and/or any other system components needed forsimulating a setup for a surgical operation.

In some implementations, only the patient side cart 106 is used in thesetup simulation. For example, a user can set up the position of thecart, the arms of the cart, and the surgical instruments of the cart,and the simulation processing component 102 can read the positions ofthese elements and provide current simulation state and feedback as tohow well the setup was performed. For example, an output device such asa display screen on the patient side cart or on another component,and/or audio speakers, can be used to output representations of thecurrent states of the setup procedure and/or feedback regarding userperformance of the setup procedure.

Some implementations of the simulated setup procedure can include theuse of an anatomical model. An assistant trainee can set up ananatomical model on an operating table. The model can be an inanimatemodel made of a rigid material and can be approximately shaped like aportion of a human patient. This model can be set up with a particularconfiguration for a particular surgical operation. For example, ininanimate training exercises, exercise devices can be placed within themodel, such as beads or rings to be manipulated on wires, rubber or foampieces of material to be sutured, cut, or otherwise manipulated withsurgical instruments. In wet lab exercises, the model can be abiological specimen such as a porcine or cadaveric model, and/or one ormore biological specimens can be placed within an inanimate model.

In some implementations of the setup procedure, the assistant traineecan position a patient side cart in an operating position next to theanatomical model. In some implementations, the simulation processingcomponent 102 can receive signals indicating the position of the patientside cart 106 and the simulation processing component can providesignals to a display such as a display screen on the patient side cart106 or vision side cart 108 which provide indications of the currentstates of the procedure and feedback to the assistant trainee as to thecorrectness of the positioning of the patient side cart relative to theanatomical model. In some implementations, the assistant can positionthe arms of the patient side cart to contact the model surface atmultiple points on the surface, which locates the model relative to thepatient side cart. The assistant trainee can then position the arms andinstruments of the patient side cart relative to the anatomical model.The assistant can select appropriate apertures in the model, placecannulas into the selected apertures of the model, and then place thesurgical instruments into the appropriate cannulas.

In some simulations, fully functional surgical instruments are providedon the arms of the patient side cart, and the trainee can insert thesurgical instruments in ports on the model. In other implementations,one or more dummy instruments are provided on the arms of the patientside cart. These dummy instruments can include base portions ofinstruments which can be inserted into cannulas, but do not include endeffectors such as claws, scissors, or scalpels.

In some implementations, manual instruments can also be used in themedical procedure in connection with the anatomical model. The assistanttrainee can place manual instruments in appropriate apertures of themodel and the positions of these instruments are tracked by thesimulation processing component.

In various implementations, a vision side cart 108 can also oralternatively be used in the setup simulation. In some implementations,the vision side cart is used with an anatomical model and a patient sidecart in the setup procedure. The user can view a model and/or the armsand instruments of a teleoperated medical device on a display screen ofthe vision side cart as captured by one or more cameras, e.g.,positioned over and/or within the model. For example, the user can viewa display screen of the vision side cart to determine if surgicalinstruments have been correctly positioned, based on the view of anendoscope which provides images of the surgical site to the displayscreen after the user has positioned the endoscope instrument. In someimplementations, a virtual environment can be displayed that models theanatomical model, physical surgical site, and/or teleoperated arms andinstruments. In some implementations, the user can be required to usecontrols on the vision side cart to control one or more functions in thesimulated procedure.

In another implementation, the vision side cart is used in the setupprocedure without the anatomical model and/or without the patient's sidecart. For example, a user can be tested in positioning of vision sidecart within the operating area, and/or the positioning of the visionside cart relative to other components such as a surgeon console.

In some implementations, one or more surgeon consoles can be included ina simulated setup procedure. For example, the positioning of the surgeonconsole within the operating area can be simulated. A surgeon traineecan also be required to perform some tasks during the setup procedure,such as port selection on an anatomical model. The surgeon console canbe used singly, or in conjunction with other components, such as apatient side cart, vision side cart, and/or anatomical model. Forexample, a setup procedure can include only the surgeon console and ananatomical model, where the positioning of the components in theoperating area, and the setup of instruments on the anatomical model aresimulated. In one example, a virtual surgical site based on the physicalside of the model can be displayed by the surgeon console while a usersets up manual instruments in the model.

Any other components of the simulation system can also be used singly orin conjunction with other components in a setup simulation. For example,the simulation processing component can monitor the used systemcomponents and the assistant can be required to position each systemcomponent correctly within an operating area or room.

In some implementations, the setup procedure can be the only simulationperformed. In other implementations, a simulation of a surgicaloperation can be performed after the setup procedure, as in an actualsurgical procedure. Alternatively, a simulated surgical operation can beperformed on its own, without a simulation of a setup procedure.

The simulation of the surgical operation can be performed using avariety of implementations. In one implementation, only the surgeonconsole is used and the simulation component provides a virtualenvironment simulation in which virtual surgical instruments aredisplayed manipulating virtual structures at a virtual surgical sitebased on user input provided by the surgeon trainee operating theconsole.

In other implementations, only the surgeon console(s) and the anatomicalmodel are used in the simulated surgical operation. For example, theteleoperated surgical instruments can be virtual instruments displayedin a virtual environment by the simulation processing component 102 andcontrolled by the console trainee. One or more real manual instrumentscan be inserted in the model and controlled by an assistant trainee,where the manual instrument position is tracked by the simulationprocessing component using sensors of the model, allowing the simulationprocessing component to display a virtual version of the manualinstrument tip, or the image-captured manual instrument, within thevirtual environment alongside the virtual teleoperated surgicalinstruments.

In another variation, the surgeon console and the patient side cart 106are used in the surgical operation. In some examples, a virtualenvironment is displayed by the simulation processing component 102,e.g., on a display of the surgeon console 104. The trainee operating thesurgeon console provides input controlling the physical arms andsurgical instruments of the patient side cart, however, the simulationprocessing component displays corresponding virtual versions of theseinstruments at the surgical site on the displays of the simulationsystem. Thus, real or dummy instruments can be used for the surgicalinstruments of the patient side cart. One example of such animplementation is shown below with respect to FIGS. 7A and 7B.

In another variation, the surgeon console and patient side cart are usedin a simulated surgical operation in which the physical surgical site isdisplayed on a display device of the surgeon console. For example, real,fully functional surgical instruments are inserted in the physicalmodel, including one or more endoscopes having cameras which captureimages of the physical surgical site (or other imaging instruments). Theimages are displayed on the console display. The console user thus seesthe actual instruments he or she is manipulating. The simulation systemcan coordinate the simulation, including record parameters, provideguidance and evaluations, etc. One example of such an implementation isshown below with respect to FIGS. 9A and 9B.

In other variations, images displayed to users can be combinations ofgenerated virtual graphics and captured images of a physical surgicalsite. For example, generated virtual instruments can be displayedalongside captured images of other, physical instruments, or images ofphysical instruments can be displayed alongside a virtual backgroundgenerated to look like an actual surgical site. In some implementations,images of the physical surgical site can be combined with augmentedimages that are displayed over portions of the images of the physicalsurgical site. For example, graphics can be overlaid on the image of thephysical site to provide feedback information such as statuses,instructions, alerts, and other information before, during, and afterthe medical procedure.

In other variations, a vision side cart is included in the system. Anyof the above displays of the surgical site can also be displayed on oneor more displays on the vision side cart that is viewed by an assistantuser. In some implementations, the surgeon console and vision side cartcan display different images or views in some implementations. Forexample, some display screens of the simulation system can display anendoscopic or camera view of the physical surgical site, while otherdisplay screens of the system can display a virtual environment thatcorresponds to the physical surgical site. For example, a camera view ofthe physical site can be displayed by the vision side cart for theassistant user to operate manual instruments at the site. Meanwhile, avirtual environment corresponding to the physical site can be displayedon the surgeon console. In another example, the vision side cart candisplay instructional feedback instead of or in addition to images ofthe surgical site displayed by the surgeon console.

FIG. 7A shows one example of a simulation system 700 including examplesof several components described herein. A surgeon console 704 canprovide controls for a user such as a surgeon or surgeon trainee, whosits at the console to manipulate the controls, and can also include thedisplay screen (shown in FIG. 5B). A patient side cart 706 includes anumber of manipulator arms 714 which include surgical instruments at theends of the arms and which are responsive to the controls operated bythe user at the surgeon console 504. An operating room table 722 ispositioned adjacent to the patient side cart 706, and can include ananatomical model 720 which can receive the surgical instruments of thepatient side cart (the model in this example is covered by the clothover the operating table). A vision side cart 708 can include a displayscreen 726 and other components, such as electronic equipment. In thisexample, the display screen 726 displays a virtual surgical sitegenerated by the simulation processing component. For example, the model720 can be only a surface or object having one or more apertures and nothaving any interior physical surgical site, where the virtual surgicalsite on screen 726 is not based on any physical corresponding site. In adifferent example, the virtual surgical site shown on screen 726 cancorrespond at least partially to a physical site included within themodel 720. The simulation processing component 102 can be located in oneor more of the components of system 700, such as the surgeon console704, the patient side cart 706, etc., or can be located in its ownhousing (not shown).

In FIG. 7B, an example display screen 740 is shown that is provided onthe surgeon console 704. In some implementations, two stereoscopicdisplay screens 740 can be provided to show a 3-D view, and/or screen740 can be a touch-responsive screen. In this example, display screen740 displays a virtual environment generated by the simulationprocessing component 104. For example, virtual instrument Ups 742 (e.g.,end effectors or other end portions) are displayed and are moved on thedisplay screen 740 based on user manipulation of the controls at console704. These displayed virtual instrument tips 742 also track the physicalinstrument tips at the patient side cart 706, which are moved within themodel 720. Objects in the environment are also displayed, such as athread 744 grasped by the instrument tips 742 used in suturing a portionof the object 746. In some implementations, the virtual thread isgenerated within the virtual environment, and/or the object 746 isgenerated as a new virtual object different from any physical objectswithin the model 720. In other implementations, the virtual thread 744can correspond to a physical thread being manipulated within the model720 by the physical instrument tips. Similarly, the manipulated object746 can also correspond to a physical object within the model 720,

In some implementations, as shown in FIG. 7A, the display screen 726 onthe vision side cart 708 can display the same environment displayed onthe screen 740 of the console 704. This allows an assistant user to viewthe scene that the console user is viewing, allowing greater assistanceduring the operation procedure.

In other implementations, an endoscope or other imaging device on thepatient side cart 706 can capture images of the physical site within themodel 720, and these images of the actual physical site can be displayedon display screen 740 and and/or display screen 726 instead of agenerated virtual environment, or in combination with some virtual,generated objects.

FIG. 8 is a perspective view of an example teleoperated medical device800 that can be included in the patient side cart 106, similar to thepatient side cart 706 shown in FIG. 7A, and an example anatomical model.Device 800 can include multiple manipulator arms, where each arm iscoupled to one or more surgical instruments. For example, each arm canbe considered a teleoperated manipulator that can be coupled (“docked”)to each port or cannula in a model for patient, and the manipulatorcontrols both the cannula and the instrument that extends through thecannula and into the model or patient to reach the physical surgicalsite. For example, one instrument 802 can be a camera or endoscopeinstrument and the three other instruments 804, 806, 808 can be surgicaloperation instruments.

An example of an anatomical model 820 is shown, used to enhance thesimulation of working on a patient in a surgical operating roomenvironment. Model 820 can include multiple holes 822 and a top surfacesimulating a surface of a patient and through which cannulas andsurgical instruments are inserted. In some implementations, one cannulaand instrument can be inserted in each hole, while in otherimplementations, multiple cannulas and/or instruments can be insertedthrough a single hole (e.g., single-site). The model 820 can include ahollow space underneath or within, which can hold one or more physicalsurgical sites 824 at which physical exercises can take placemanipulating exercise objects, such as flexible materials, thread, beadson wires, etc.

Model 820 is placed on an operating table (such as table 722 describedabove) at a location corresponding to a patient's position on the table.In some implementations of setup simulation procedures, differentsurgical operations may require various different port placements, and auser being trained may have to position the device 800 in one locationfor one surgical operation (e.g., at the foot of the operating table,simulating a location between the patient's legs) and in a secondlocation for another surgical operation (e.g., to the side the operatingtable). Some examples of anatomical model 820 and exercises aredescribed in copending patent application Ser. No. 13/968,253, entitled,“Anatomical Model and Method for Surgical Training,” which isincorporated herein by reference in its entirety.

FIG. 9A shows another example 900 of a simulation system includingexamples of several of the components described herein. Similarly toFIG. 7A, a surgeon console 904 can provide controls for a user and canalso include one or more display screens (example shown in FIG. 9B). Apatient side cart 906 includes a number of manipulator arms 914 whichinclude surgical instruments at the ends of the arms and which areresponsive to the controls operated by the user at the surgeon console904. An operating room table 922 is positioned adjacent to the patientside cart 906, and can include an anatomical model 920 similarly asdescribed above. A vision side cart 908 can include a display screen 926and other components, such as electronic equipment. In this example, thedisplay screen 926 displays a virtual environment similar to theenvironment displayed on the screen of the surgeon console as describedbelow in FIG. 9B. A component corresponding to simulation processingcomponent 102 can be located in one or more of the components of system900 similarly as described above.

Simulation system 900 can also include manual surgical instruments, suchas manual instrument 930 which is shown as a laparoscopic instrument. Insome implementations, a manual instrument 930 can be guided andmanipulated by an assistant user into or relative to model 920 duringsimulated surgical operations, while a surgeon user controlsteleoperated surgical instruments using the surgeon console 904. Thesurgeon trainee an assistant trainee can train together during asimulation. In other implementations, the surgeon trainee can operatethe surgeon console 904 and can operate one or more manual instruments930, e.g. Where one or more telemanipulated instruments can be operatedby the simulation system (e.g., an endoscopic instrument). Someimplementations can enable the simulation of a surgical operation usingteleoperated instruments, and then enable the simulation of that samesurgical operation using one or more manual instruments. The results ofthese two simulations can then be compared by the system, and resultssummarized. Some implementations including manual instrument 930 aredescribed below.

In FIG. 9B, an example display screen 940 is shown that can be providedon the surgeon console 904. In this example, display screen 940 displaysa virtual environment generated by the simulation processing component104, which can be a 2D or 3D environment, and can be displayed on atouch-responsive screen in some implementations. In this example, thevirtual environment presents a realistic background of the interiorsimulating an actual patient surgical site within an actual patient,including body tissue and other body components instead of the generatedexercise environment of FIG. 7B. Virtual instrument tips 942 aredisplayed and are moved on the display screen 940 based on usermanipulation of the controls at console 904. The displayed instrumenttips 942 also track the physical instrument tips of the patient sidecart 906, which are moved at a physical surgical site within the model920.

Objects in the virtual environment are also displayed, such as a ring944 grasped by an instrument tip or end effector 942 a and moved along atrack 946 following a virtual object 948 as an exercise. In someimplementations, the ring 944 and wire track 946 can have physicalcorresponding objects provided in the model 920 which are manipulated bythe physical instruments corresponding to the virtual instruments 942.In other implementations, there need not be corresponding physicalobjects to one or more of the virtual objects. For example, none of thevirtual objects need correspond to physical instruments, where thephysical instruments of the patient side cart can be dummy instruments.Or, just the virtual instruments can correspond with physicalinstruments, which interact with nothing in the model.

For example, instrument tip 942 b can be grasping a virtual object 950which has no physical corresponding object at the physical site in themodel 920. In some implementations, haptic output can be provided on thecontrols of the surgeon console 904 using one or more actuators of thesurgeon console, to provide the user the sensation of manipulating theobject 950.

In some implementations, an instrument tip 952 can be displayed onscreen 840 and within the virtual environment. For example, tip 952 cancorrespond to a manual instrument, such as manual instrument 930 shownin FIG. 9A, that has been inserted in the anatomical model 920. Thephysical end or tip of instrument 930 can be tracked within model 920 asdescribed in some implementations herein, and its corresponding virtualtip 952 moved accordingly within the virtual environment of screen 940.For example, the virtual tip 952 can be displayed to interact withvirtual objects that correspond with physical objects in the model 920,and/or with virtual objects with no corresponding physical objects.

FIGS. 10A-10C illustrate examples related to tracking instruments withinan anatomical model. FIG. 10A is a diagrammatic illustration of anexample implementation 1000 of a patient side cart 1002 and ananatomical model 1004. Manipulator arms 1006 a, 1006 b, and 1006 c ofthe patient side cart 1002 include operating instruments that aresurgical instruments 1008 a, 1008 b, and 1008 c, respectively, andmanipulator arm 1006 d includes an operating instrument that is anendoscopic instrument 1008 d. Each of the instruments 1008 a-d isinserted in an associated cannula 1010 a, 1010 b, 1010 c, or 1010 d,respectively (e.g., the instrument can be a trocar within a cannula1010, or a cannula 1010 can be part of a trocar 1008 in some examples,such as for an initial insertion in the model 1010). The cannulas 1010are inserted in apertures of the model 1004.

For example, the endoscope instrument 1008 d can have its own sensingreference origin 1014 relative to which it can sense the instruments andcannulas inserted in the model 1004. For example, the endoscope cameracan capture images of the cannulas 1010 within the model when they aremoved into the view of the camera.

The model 1004 can also include its own sensing system for trackinginstruments inserted in (or otherwise interacting with) the model 1004.In the example implementation of FIG. 10A, one or more sensors areprovided within the model 1004 to sense the cannulas 1010. In thisexample, a camera system 1020 is positioned on the interior base of themodel 1004 to sense the interior of the mode 11004. For example, acamera system 1020 can be positioned near or within a patient sideelement (PSE) such as model 1004, or can be positioned at otherlocations of the bottom or sides of the model. Camera system 1020 thuscontinually capture images showing the positions of cannulas 1010 beinginserted in the model, as well as images showing the positions ofsurgical instruments 1008 inserted through the cannulas 1010. Camerasystem 1020 thus has its own sensing reference origin 1022 which is thereference point for images captured by the camera system. In the exampleof FIG. 10A, two cameras are shown in the camera system 1020 to allowstereo triangulation in determining positions of the cannulas 1010 inthe anatomic model. In other implementations, camera system 1020 caninclude a single camera, or other types of sensors to capture positionor motion of cannulas and instruments.

FIG. 10B shows example views 1050 of a camera system within ananatomical model, such as camera system 1020 with an model 1004 of FIG.10A. The camera system 1020 includes two cameras, and a left view 1052is the view of one of the cameras, and a right view 1054 is the view ofthe other camera. The top surface 1056 and bottom surface 1058 areshown, as well as apertures 1060 in the top of the model. Cannulas 1010can be viewed inserted through specific holes of the model. In thisexample having two cameras, stereo triangulation can be used toaccurately determine the position of each cannula 1010 with reference tothe origin system of the cameras. In some implementations, each cannula1010 can be distinguished from each other cannula 1010 with individualmarks or other characteristics. For example, each cannula 1010 can havea different exterior color to allow easy distinguishment of each cannula1010 by the sensing system 1020.

FIG. 10C shows a plan view of the external surface of the top surface ofmodel 1004, including holes 1060 in the surface. Marks 1070 indicateparticular holes through which the cannulas 1010 were detected by thecamera system 1020 to have been inserted. Such a view can be created bythe simulation processing component 104 based on the sensing views ofthe camera system 1020 and (for example) a 3-D computer-aided design(CAD) model of the anatomical model 1004 used in visualization software.The view of FIG. 10C can be used to display port placement for the modelfor instructional or guidance purposes during a simulated medicalprocedure. For example, the view showing marked used ports can bedisplayed next to a similar view that displays the correct ports to beused in the particular medical procedure being simulated.

Manual instruments can be tracked by sensing system 1020 similarly tothe cannulas and teleoperated instruments described above. For example,a manual laparoscopic tool can be tracked. Other instruments can includea uterine manipulator, retraction tool, needle-passing tools, anothermanipulator arm or instrument attached to a separate component of thesimulation system, or other instruments where an instrument or deviceseparate from the patient side cart is being tracked and incorporatedinto the simulation environment.

FIGS. 11A and 11B are diagrammatic illustrations of one example of theuse of an anatomical model 1100 in simulated medical procedures thatincludes the use of both teleoperated and manual surgical instruments.FIG. 11A is an exterior view of the model 1100 and inserted instruments,and FIG. 11B is an interior view of the model 1100. Model 1100 can besimilar to models described above and includes apertures 1102 in anupper shelf portion of the model, through which cannulas 1104 have beeninserted during a setup procedure. Teleoperated surgical instruments,such as laparoscopic instruments and endoscopes, can be inserted in thecannulas 1104. Alternatively, manual surgical instruments, such asmanual laparoscopic instrument 1110, can be inserted in one or more ofthe cannulas 1104.

In this implementation, sensors can be provided within the model 1100 tosense the cannulas 1104 and manual instruments such as instrument 1110.In this example, camera system 1112 is positioned on the interior baseof the model 1100 to sense the interior of the model 1100 similarly asdescribed for FIG. 10A. Camera system 1112 can thus capture imagesshowing when cannulas 1104 have been inserted in the model, as well asimages showing when surgical instruments have been inserted in thecannulas 1104. In some implementations, since the positions ofteleoperated surgical instruments are already known based on sensors inthe teleoperated arms, such instruments do not need to be tracked, anddummy instruments can be used, e.g., which do not extend into theinterior hollow portion of model 1100.

Other types of sensors instead of cameras can be used in otherimplementations. For example, electromagnetic sensors, other opticalsensors, etc. can be used to sense cannulas and manual surgicalinstruments.

FIG. 12 is a flow diagram illustrating an example method for using ananatomical model with both teleoperated surgical instruments and manualsurgical instruments in one or more simulated surgical procedures, withreference to FIGS. 11A-11B. In some implementations, blocks 1202 to 1208can be performed during a simulated setup procedure, and blocks 1210 and1212 can be performed during a simulated surgical operation (block 1210can also be performed during a simulated setup procedure).

In block 1202, the simulation processing component 102 can receive aposition of the model 1100 relative to the teleoperated arms of thepatient side cart. For example, a teleoperated instrument at the end ofone of the arms can be moved to contact (register) the model in multiplelocations to establish the location of the mode in 3-D space. In otherimplementations, block 1202 can be omitted or performed at a later time,e.g., the model location can be determined relative to the teleoperatedinstruments after docking instruments to cannulas in block 1206 below byusing sensors in the teleoperated arms.

In block 1204, the simulation processing component senses the insertionof cannulas 1104 in the model 1100 and the simulation processingcomponent estimates the position and orientation of the cannulas 1104.For example, sensors like camera system 1112 can send signals to thesimulation processing component. In block 1206, the simulationprocessing component senses docking and insertion of teleoperated dummyinstruments in cannulas 1104, e.g., based on signals from the sensors inthe manipulator arms of the patient side cart. In other implementations,full surgical instruments can be docked and inserted in the cannulas1104. In block 1208, the sensors (such as camera system 1112) andsimulation processing component sense insertion of one or more manualinstruments in cannulas 1104, such as instrument 1110. Blocks 1206 and1208 can be performed in any order and/or at least partiallysimultaneously. In block 1210, the simulation processing componentgenerates a virtual environment and generates virtual surgicalinstruments in the virtual environment corresponding to the teleoperatedsurgical instruments and the manual surgical instruments. In block 1212,the simulation processing component runs the simulated surgicaloperation based on console signals, sensed teleoperated instruments, andsensed manual surgical instruments.

Some implementations of method 1200 can use the sensing system of theanatomical model and/or the teleoperated medical device in conjunctionwith displaying a virtual environment. In some examples, a genericpicture of the model can be displayed without the teleoperated arms andwithout the exact position/orientation of the model relative toteleoperated arms. For example, the port locations placed by a user canbe identified using cameras inside the model without using theteleoperated arm kinematics. Instruction can be given to the user toadjust incorrect port locations before beginning to dock theteleoperated arms to the model. Once docked, the arm kinematics can beused to estimate the position and orientation of the model relative tothe teleoperated medical device. (Other implementations can use sensorsplaced in or on the anatomical model to estimate the pose and locationof the model relative to the patient side cart, rather than using theteleoperated arm sensors.) An entire scene of the surgical site and/oroperating room can then be displayed to trainees. In someimplementations, sensors in the model can track surgical instruments toprovide an estimate of where the model is relative to the teleoperateddevice and this estimate of location can be updated during a procedureor operation to continuously provide accurate relative model location incase the model is bumped or moved by trainees.

FIGS. 13A and 13B are diagrammatic illustrations of an example of theuse of an anatomical model 1300 in simulated medical procedures thatinclude the use of manual surgical instruments. Model 1300 can besimilar to the models described above. FIG. 13A is an exterior view ofthe model 1300 and an inserted instrument, and FIG. 13B is an interiorview of the model 1300. Model 1300 includes apertures 1302 in an upperportion of the model. Particular apertures 1306 can be designated asremote centers for teleoperated instruments typically inserted throughthese apertures, but no cannulas for teleoperated instruments need beplaced in this implementation. One or more cannulas, such as cannula1304, are inserted in model 1300 during a setup procedure in apertureswhere manual instruments are to be inserted. Manual surgicalinstruments, such as manual laparoscopic instrument 1310, can beinserted in the cannula 1304.

Sensors can be provided within the model 1300 to sense the cannulas suchas cannula 1304 and manual instruments such as instrument 1310. In thisexample, camera system 1312 is positioned on the interior base of themodel 1300 to sense the interior of the model 1300. Camera system 1312can capture images showing when cannula 1304 has been inserted in themodel, as well as images showing when manual surgical instruments havebeen inserted in the cannula 1304. The apertures 1306 for teleoperatedsurgical instruments can be located by the simulation processor based onthe known geometry of the model and the particular medical procedurebeing simulated. Thus these particular aperture locations can be assumedarm remote centers, and no cannulas need to be tracked, nor do anyteleoperated surgical instruments need to be docked with the model. Thusthis implementation can be used for simulations that include the use ofmanual surgical instruments and do not need use of a patient side cart,e.g., the teleoperated surgical instruments can all be virtualinstruments generated in a virtual environment provided by thesimulation processing component.

Other types of sensors instead of cameras can be used in otherimplementations. For example, electromagnetic sensors, other opticalsensors, etc. can be used to sense cannulas and manual surgicalinstruments.

FIG. 14 is a flow diagram illustrating an example method 1400 for usingmanual surgical instruments in a simulated medical procedure, withreference to FIG. 13 . In some implementations, blocks 1402 to 1406 canbe performed during a simulated setup procedure, and blocks 1408 and1410 can be performed during a simulated surgical operation (block 1408can also be performed during a setup procedure).

In block 1402, the simulation processing component 102 assumes theposition and orientation of the model 1300, including assuming thepositions of the surgical site and the apertures in the model (remotecenters of teleoperated instruments) through which teleoperated surgicalinstruments would be inserted. To do this, the simulation processingcomponent knows the geometry of the model and its apertures and physicalsurgical site location, as well as the particular apertures used in thesurgical operation being set up. In block 1404, the simulationprocessing component senses the insertion of cannulas 1304 in the model1300 using sensors of the model 1300 and the simulation processingcomponent estimates the position and orientation of the cannulas 1304.In block 1406, the simulation processing component senses insertion ofone or more manual instruments in cannulas 1304, such as instrument1310. In block 1408, the simulation processing component generates avirtual environment and generates virtual surgical instruments in thevirtual environment corresponding to teleoperated surgical instrumentsand the manual surgical instruments. The relative position between themanual surgical instruments and the assumed aperture locations for theteleoperated instruments in the model 1300 enable relative positioningof these instruments in the virtual environment. In block 1410, thesimulation processing component runs the simulated surgical operationand updates the virtual environment based on console signals (to movethe virtual teleoperated surgical instruments) and sensed manualsurgical instruments.

Features described herein offer a wide variety of functionality andadvantages in various simulation implementations. For example, asimulation processing component (e.g., processing unit) can interactwith a surgeon console (e.g., with master controllers) and/or a patientside cart (e.g., with slave manipulator arms and instruments). Theconsole master can drive the slave arms with or without instruments (orwith dummy instruments) on the patient side cart.

The simulation system can simulate and provide guidance and otherfeedback on system setup and accurate positioning of the manipulatorarms prior to a simulated surgical operation. This can be used toprovide standardized and consistent training to surgeons using inanimatetraining exercises or wet-lab exercises. A simulated surgical operationcan follow the simulated setup procedure, which can allow the entiremedical procedure to be simulated. This allows trainees to see theconsequences of improperly-performed tasks. For example, improper orincorrect tasks performed in a setup procedure may have repercussions ina following surgical operation, and the simulation system hereinsimulates this entire effect to allow trainees to learn and improve.

The simulation system can display a virtual environment (e.g., ignoreendoscope feed and instruments if installed), combined or augmentedenvironment (e.g., endoscope feed with generated graphical visualoverlays or virtual environment objects), or entirely visual imaging(e.g., endoscopic) feed. For example, some implementations can displaythe virtual environment and/or endoscopic video feed from the patientside cart on the surgeon console display screen and on one or moreexternal display screens (e.g., in 2D or 3D). In some examples, virtualor augmented images can be output through display systems (such as usingTilePro from Intuitive Surgical, Inc.) on the surgeon console during anytraining exercise to provide instruction or performance metrics. Forexample, virtual reality (VR) or other generated images, and/oraugmented reality (AR) ghost images overlaid on camera images, can bedisplayed on system display devices to indicate or highlight systemareas of concern or interest, such as patient cart setup joints havingincorrect positions highlighted, reachability limits of instrumentsdisplayed, and/or internal/external collisions. This can reduce theburden on training assistants to catch mistakes during trainingprocedures.

The system can record the kinematics and events of the master console(s)and teleoperated slave medical device(s) during completion of inanimatetraining or wet-lab exercises by a console surgeon to compute trainingmetrics and display such metrics using a similar interface as purelyvirtual training exercises. Additionally or alternatively, the systemcan record the kinematics and events of teleoperated devices duringcompletion of patient-side exercises and setup procedures using actualinstruments, and compute training metrics and display such metrics usinga similar interface as purely virtual training exercises. Further, thesystem can record the kinematics and events of the masters and slavesduring completion of exercise modules on porcine models (for example,during offsite training) to provide metrics and display such metrics.Such detailed collection of data and quantification and tracking oftrainee performance allows trainees and simulation operators to reviewtraining progress in high detail, leading to insights and improvementsin individual trainee progress as well as training procedures, and thuspermits overall greater training effectiveness.

All data from any training environment or configuration can be recordedand stored locally or remotely in the same way to improve accessibilityof data, monitoring of surgeon training and performance of traineepersonnel during simulated procedures, standardization of exercises, andfeedback to surgeon during training (e.g., to improve surgeon training).The simulation system can centralize most training content to onesoftware platform separate from the system architecture, which can avoiddifficulties of changing system software to accommodate training(potentially leading to FDA issues, etc.).

Teleoperated medical device surgery offers an unprecedented ability torecord, track, and monitor surgery and surgeon training unlike anypre-existing form of surgery. Implementations described herein can makeeffective use of this capability and the data that can be harvestede.g., for simulation and training purposes. Some additional advantagesof various implementations of teleoperated and non-teleoperated systemscan include the following.

Features described herein can centralize user training and evaluation ona single system, e.g., a single teleoperated medical system. Somesystems can provide the ability to use a single simulation framework onteleoperated medical system with a separate surgeon console and patientside cart to monitor and track progress and to display feedback allunder a single software and user interface (UI) framework. Some systemscan provide the ability to provide augmented reality output and feedbackduring wet-lab or porcine model exercises and dry-lab exercises using ateleoperated medical system. Some systems can provide the ability tocombine training data using a single software and hardware architectureused for various types of training exercises including virtualenvironment exercises, inanimate exercises, wet-lab or porcine models,etc. One or more features can allow any training exercise or offsite labexercise to be conducted using the single simulation architecture toprovide real-time (during a procedure) and end-of-exercise metrics toguide training and learning.

Features herein can improve accessibility of training data, especiallyfor tasks not normally implemented on a simulator system. Features canimprove standardization of training since the system can be used forseveral types of training tasks. Features can improve surgeon trainingat offsite training labs by quantifying and delivering feedback inaddition to that provided by training personnel to help trainees learn.Also, features can help training personnel to better manage multiplesurgeon trainings simultaneously (e.g., dual surgeon console trainings).

Furthermore, features can improve surgeon training conducted by clinicalsales representatives (CSRs) or other instructors by simulating tasksperformed during setup procedures, and by providing feedback determinedby the system and displayed in real-time for setup exercises.

Features described herein can expand the capability of teleoperated andnon-teleoperated medical simulation systems to support inanimatetraining exercises, wet-lab training scenarios, and VR-based trainingexercises. A single simulation system can administer and record alltraining performed by surgeons, e.g., with their CSRs, with dedicatedtraining specialists (TSs), or independently. The simulation system canbe used to simulate all interactions with the system outside of actualsurgery.

It should be noted that the blocks described in the various methodsherein can be performed in a different order than shown and/orsimultaneously (partially or completely) with other blocks in the samemethod (or other methods), where appropriate. In some implementations,blocks can occur multiple times, in a different order, and/or atdifferent times in the methods.

This description and the accompanying drawings that illustrate featuresand implementations should not be taken as limiting. Various mechanical,compositional, structural, electrical, and operational changes may bemade without departing from the spirit and scope of this description andthe claims. In some instances, well-known circuits, structures, ortechniques have not been shown or described in detail in order not toobscure described features.

Further, this description's terminology is not intended to limit thescope of the claims. For example, spatially relative terms—such as“beneath”, “below”, “lower”, “above”, “upper”, “proximal”, “distal”, andthe like—may be used to describe one element's or feature's relationshipto another element or feature as illustrated in the figures. Thesespatially relative terms are intended to encompass different positions(i.e., locations) and orientations (i.e., rotational placements) of adevice in use or operation in addition to the position and orientationshown in the figures. For example, if a device in the figures is turnedover, elements described as “below” or “beneath” other elements orfeatures would then be “above” or “over” the other elements or features.Thus, the exemplary term “below” can encompass both positions andorientations of above and below. A device may be otherwise oriented(rotated 90 degrees or at other orientations) and the spatially relativedescriptors used herein interpreted accordingly. Likewise, descriptionsof movement along and around various axes includes various specialdevice positions and orientations. In addition, the singular forms “a”,“an”, and “the” are intended to include the plural forms as well, unlessthe context indicates otherwise. Components described as coupled may beelectrically or mechanically directly coupled, or they may be indirectlycoupled via one or more intermediate components.

Elements described in detail with reference to one implementation may,whenever practical, be included in other implementations in which theyare not specifically shown or described unless the one or more elementswould make an implementation non-functional or provide conflictingfunctions. For example, if an element is described in detail withreference to one embodiment and is not described with reference to asecond embodiment, the element may nevertheless be included in thesecond embodiment.

The functional methods, blocks, features, devices, and systems describedin the present disclosure may be integrated or divided into differentcombinations as would be known to those skilled in the art. Disclosedmethods and operations may be presented in a specific order, but theorder may be changed in different particular implementations. In someimplementations, multiple steps or blocks shown as sequential in thisdisclosure may be performed at least partially at the same time.

1-22. (canceled)
 23. A method comprising: determining a position of asystem component relative to a physical surgical site, wherein thesystem component is positioned relative to the physical surgical siteduring a setup procedure and wherein the system component is movableindependently of the physical surgical site; determining a position of ateleoperable medical device relative to the physical surgical site,wherein the teleoperable medical device is positioned relative to thephysical surgical site during the setup procedure; storing, by at leastone processor, in a storage device, the position of the system componentand the position of the teleoperable medical device; and performingoperations in a simulated surgical procedure based on the position ofthe system component and the position of the teleoperable medicaldevice.
 24. The method of claim 23, further comprising determining,during the setup procedure, whether one or more particular joints of theteleoperable medical device are incorrectly positioned based on acomparison with reference joint positions.
 25. The method of claim 23,wherein the position of the system component is in a simulation area andis provided by a user, and the position of the teleoperable medicaldevice is provided by the user.
 26. The method of claim 25, furthercomprising causing output of setup feedback information by an outputdevice based on a result of comparing the position of the systemcomponent to a reference position, the setup feedback informationindicating an evaluation of the position of the system componentprovided by the user.
 27. The method of claim 25, further comprisingcausing output of setup feedback information by an output device basedon a result of comparing the position of the teleoperable medical deviceto a reference position, the setup feedback information indicating anevaluation of the position of the teleoperable medical device providedby the user.
 28. The method of claim 23, wherein performing theoperations in the simulated surgical procedure includes reading positionsignals for the teleoperable medical device that describe at least oneof a position or a configuration of the teleoperable medical devicerelative to the physical surgical site, wherein the at least one of theposition or the configuration is based on control signals based on userinput to a control device during the simulated surgical procedure. 29.The method of claim 23, wherein performing the operations in thesimulated surgical procedure includes: comparing at least one of: aposition of the teleoperable medical device to a reference position or aconfiguration of the teleoperable medical device to a referenceconfiguration; and causing output of surgical feedback information by anoutput device, wherein the surgical feedback information is based on aresult of the comparing.
 30. The method of claim 23, wherein performingthe operations in the simulated surgical procedure includes: determiningwhether an incorrect setup is present during the simulated surgicalprocedure based on the position of the teleoperable medical device; andin response to determining that the incorrect setup is present, causingoutput of surgical feedback information by an output device to indicatean effect of the incorrect setup on the simulated surgical procedure.31. The method of claim 23, wherein the physical surgical site comprisesan anatomical model, and the method further comprises receiving, by theat least one processor, a sensor signal from at least one sensor of theanatomical model, the sensor signals indicative of a position of theteleoperable medical device relative to the anatomical model.
 32. Themethod of claim 23, wherein performing the operations in the simulatedsurgical procedure includes: generating a virtual environment based atleast in part on the position of the teleoperable medical device;updating the virtual environment according to changes in the position ofthe teleoperable medical device, the changes based on control signalsfrom a user control device; and after the updating, causing output by anoutput device of a representation of a current state of the virtualenvironment.
 33. The method of claim 23, wherein the system componentincludes a vision side cart that includes a display device, wherein thevision side cart is moveable in a simulation area independently of thephysical surgical site and of the teleoperable medical device.
 34. Themethod of claim 23, wherein the position of the teleoperable medicaldevice is provided by a user during the setup procedure in setup tasksthat include installation of a surgical instrument on a manipulator armof the teleoperable medical device.
 35. A system comprising: asimulation processing component including at least one processor; ateleoperable medical device moveable relative to a physical surgicalsite; and a system component movable relative to and independently ofthe physical surgical site, wherein the simulation processing componentis configured to perform operations comprising: determining a positionof the teleoperable medical device relative to the physical surgicalsite, wherein the teleoperable medical device is positioned relative tothe physical surgical site during a setup procedure; determining aposition of the system component relative to a physical surgical site,wherein the system component is positioned relative to the physicalsurgical site during the setup procedure; storing, by at least oneprocessor, in a storage device, the position of the system component andthe position of the teleoperable medical device; and performingoperations in a simulated surgical procedure based on the position ofthe teleoperable medical device and the position of the systemcomponent.
 36. The system of claim 35, wherein the simulation processingcomponent is configured to perform further operations comprising:determining whether an incorrect setup is present during the simulatedsurgical procedure based on the position of the teleoperable medicaldevice; and in response to determining that the incorrect setup ispresent, causing output of surgical feedback information by an outputdevice to indicate an effect of the incorrect setup on the simulatedsurgical procedure.
 37. The system of claim 35, wherein the position ofthe system component is in a simulation area and is provided by a user,and the position of the teleoperable medical device is provided by theuser.
 38. The system of claim 37, wherein the simulation processingcomponent is configured to perform further operations comprising causingoutput of setup feedback information by an output device based on aresult of comparing the position of the system component and theposition of the teleoperable medical device to reference positions, thesetup feedback information indicating an evaluation of the position ofthe system component and the teleoperable medical device provided by theuser.
 39. The system of claim 35, wherein the teleoperable medicaldevice includes a manipulator arm and a surgical instrument connected tothe manipulator arm, wherein the teleoperable medical device ispositioned in a simulation area relative to the physical surgical site.40. The system of claim 35, wherein, during the setup procedure, theteleoperable medical device is positioned relative to the physicalsurgical site by manual movement of teleoperable medical device by atrainee, and wherein, in the simulated surgical procedure, theteleoperable medical device is positioned relative to the physicalsurgical site based on control signals based on user manipulation of acontrol device.
 41. The system of claim 35, wherein performing theoperations in the simulated surgical procedure includes reading positionsignals for the teleoperable medical device that describe at least oneof a position or a configuration of the teleoperable medical devicerelative to the physical surgical site, wherein the at least one of theposition or the configuration is based on control signals based on userinput to a control device during the simulated surgical procedure. 42.The system of claim 35, wherein the system component includes a visionside cart that includes a display device, wherein the vision side cartis moveable in a simulation area independently of the physical surgicalsite and of the teleoperable medical device.